Intake Form
Wesley Macintyre Psychology
Confidentiality
The information provided in this form is held in the same strict confidence as client sessions, ensuring utmost privacy and protection. Rest assured that your personal information will be handled with the utmost respect.
Are you completing this form on behalf of someone who is under 18?
No
Yes
Client's Name
First Name
Last Name
D.O.B of the client
*
-
Day
-
Month
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Will you be applying for the medicare rebate for therapy (e.g mental health care plan)?
Yes
Unsure
no
Briefly describe your current concerns or reason/s for referral
Indicate your overall mood over last four weeks
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
Indicate your overall level of anxiety over the past two weeks
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
I understand that Wesley Macintyre Psychology does not currently see clients pertaining to: Family therapy, work cover referrals, psychometric assessment (cognitive assessment, ADHD assessment, Autism etc.), court or custody processes.
Yes
Have you ever experienced 'ups' where you feel so good or 'hyper' that you or others don't think you are your normal self?
Yes
No
In the past 3 months, have you had an intense fear of gaining weight?
Yes
No
In the past 3 months, have you been deliberately trying to limit the amount of food you eat to influence your weight or shape?
Yes
No
In the past 3 months, have you ever used any of the following methods to control your weight: excessive exercise, making yourself throw up, laxatives/diuretics?
Yes
No
In the past 3 months, have you ate a very large amount of food in one sitting until uncomfortably full, and worried you have lost control?
Yes
No
Are you or someone you know (e.g., family, friends, G.P) worried about your level of alcohol consumption?
Yes
No
Have there been any times in the past 12 months that you have used an illegal substance or a prescription medication for non-medical reasons?
Yes
No
Is treatment for addiction (alcohol or substance use, gambling, other) your primary concern for seeking an appointment)
Yes
No
Have you previously received a diagnosis of a personality disorder?
Yes
No
Have you ever received a diagnosis of an intellectual disability?
Yes
No
Where did you here about Wesley Macintyre Psychology
Bark.com
GP referral
Website
Other
Submit
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