Enquiry Form

1
Date
Date
Day
Month
Year
2
What is your best email address?* This field is required.
example@example.com
3
What is your best contact phone number?* This field is required.
Please enter a valid phone number.
4
Is there a psychologist you would prefer? (you may select more than one)* This field is required.
I don't mind (I want one that suits my needs)
Yvette Zevon
Madi Fuge
Ivan Mathieson (not taking new clients)
Kezia Matheson
Justin McNamara (not taking new clients)
Bec Powers
Marie Camin (not taking new clients)
Amy Whittle-Herbert
5
Are you seeking help for a child or an adult?* This field is required.
Child
Adult
6
Child's Name* This field is required.
First Name
Last Name
7
Child's Date of Birth* This field is required.
Date
Day
Month
Year
8
Your Name* This field is required.
First Name
Last Name
9
Are the parents of the child separated or divorced* This field is required.
Yes
No
10
Are there court orders in place?* This field is required.
Yes
No
11
Do both parents consent to the child seeing a psychologist?* This field is required.
Yes
No
12
What is the full name of the other parent?
First Name
Last Name
13
What is the best contact number for the other parent?
Please enter a valid phone number.
14
What is the best email address for the other parent?
example@example.com
15
What is the adult's name?* This field is required.
First Name
Last Name
16
What is the adult's date of birth?* This field is required.
Date
Day
Month
Year
17
Primary Concerns: Please describe what the main issues are that you need help with.* This field is required.Please give as much detail as possible. This will help us chose the most suitable psychologist and help us ensure we are the right practice for you.
18
What type of service(s) are you after?* This field is required.
Therapy or Intervention
Intervention for motor tics/vocal tics/Tourette's disorder
Parenting support
Formal Autism Assessment
Formal ADHD assessment
Formal learning/educational/cognitive assessment (including dyslexia)
Other
19
Goals of therapy/assessment: what would you like to achieve from coming to see us?* This field is required.
20
Are there any current concerns with relation to suicide or self harm (please specify):* This field is required.
No
Yes
21
Please provide some more detail regarding suicidal thinking and/or self-harm* This field is required.
22
Are there any current or previous diagnoses? (tic all that apply)* This field is required.
None
Autism
ADHD
Obsessive Compulsive Disorder
Tourette's Disorder or Tic Disorder
Dyslexia or other Learning Disorder
Depression
an Anxiety Disorder
an Eating Disorder
Other
23
Do you have NDIS Funding which you wish to use to for psychology sessions?
Yes
No
24
How is your NDIS funding managed?
Agency/NDIS Managed
Plan Managed
Self Managed
I am not sure
25
IMPORTANT INFORMATION* This field is required.Please note, as we are not an NDIS registered provider, clients who are NDIA or Agency managed cannot use NDIS funding for services at our clinic. If you wish to see one of our psychologists, you will need to pay privately. You may be eligible for a partial Medicare rebate with a Mental Health Care Plan from your GP, Paediatrician, or Psychiatrist.
26
IMPORTANT INFORMATION* This field is required.Please note, as we are not an NDIS registered provider, clients who are NDIA or Agency managed cannot use NDIS funding for services at our clinic. If you wish to see one of our psychologists, you will need to pay privately. You may be eligible for a partial Medicare rebate with a Mental Health Care Plan from your GP, Paediatrician, or Psychiatrist.
27
Important Information Regarding our Fees* This field is required.Please note our session fee is above the NDIS hourly rate. As such, for all appointments, there will be a gap fee of approximately $67 (and $85 for the initial appointment). This needs to be paid privately, and there is no rebate available for this amount.
28
Other relevant information: is there anything else that you think we should know?
Huge
Large
Normal
Small
Ok
Ok
29
Client DOB regardless of type
Date
Day
Month
Year
30
AGE
31
CLIENT NAME
Last Name
First Name
32
Pre- CLIENT NAME
Last Name
First Name
33
ASANA Age
34
Referral letter(s)Please add referral letter(s) and any assessment reports below if you have any
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
Should be Empty: