Enquiry Form

1

Date

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 (has a waitlist)

Ivan Mathieson (not taking new clients)

Kezia Matheson (has a waitlist)

Justin McNamara (not taking new clients)

Bec Powers

Marie Camin (not taking new clients)

Zoe Lazaridis

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

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

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

Please let us know your availability below. There are limited to no appointment times available after 3 pm, and demand is higher for later appointments, so you will be seen sooner if you make yourself available for as many times as possible. Those who select only a few times that are in high demand may wait many months longer.

20

Which days can you do appointments?* This field is required.Unfortunately we do not currently offer appointments on weekends.

Monday

Tuesday

Wednesday

Thursday

Friday

21

Morning (9–11 am)* This field is required.

Can't do

Can do

Preferred time

22

Middle of the day (11 am–2 pm)* This field is required.

Can't do

Can do

Preferred time

23

Afternoon (2–5 pm)* This field is required.

Can't do

Can do

Preferred time

24

Goals of therapy/assessment: what would you like to achieve from coming to see us?* This field is required.

25

Additional comments about your availability

26

Are there any current concerns with relation to suicide or self harm (please specify):* This field is required.

No

Yes

27

Please provide some more detail regarding suicidal thinking and/or self-harm* This field is required.

29

Do you have NDIS Funding which you wish to use to for psychology sessions?

Yes

No

30

How is your NDIS funding managed?

Agency/NDIS Managed

Plan Managed

Self Managed

I am not sure

31

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.

32

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.

33

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.

34

Can your child attend appointments during school hours?* This field is required.

Yes, any day

Yes, on some days

No, outside school hours only

35

Can you attend appointments between 9am and 3pm on weekdays?* This field is required.

Yes, any day

Yes, on some days

No, only after 3pm

36

Which days could work for appointments?* This field is required.Tip: the more days and times you select, the shorter your wait is likely to be.

Monday

Tuesday

Wednesday

Thursday

Friday

37

Monday: which times could work?* This field is required.Tip: the more times you select, the shorter your wait is likely to be.

9–11am

11am–3pm

3–4pm

4–5pm

38

Tuesday: which times could work?* This field is required.Tip: the more times you select, the shorter your wait is likely to be.

9–11am

11am–3pm

3–4pm

4–5pm

39

Wednesday: which times could work?* This field is required.Tip: the more times you select, the shorter your wait is likely to be.

9–11am

11am–3pm

3–4pm

4–5pm

40

Thursday: which times could work?* This field is required.Tip: the more times you select, the shorter your wait is likely to be.

9–11am

11am–3pm

3–4pm

4–5pm

41

Friday: which times could work?* This field is required.Tip: the more times you select, the shorter your wait is likely to be.

9–11am

11am–3pm

3–4pm

4–5pm

42

If we can't offer your preferred times straight away, would you be open to…

A different time with the same psychologist

A different psychologist with sooner availability

Waiting for a preferred time

43

Is there a time that would suit best, or anything else we should know about availability?Optional: add anything else about days, times, or scheduling constraints.

44

Other relevant information: is there anything else that you think we should know?

45

Client DOB regardless of type

Date

46

AGE

47

CLIENT NAME

Last Name

First Name

48

Pre- CLIENT NAME

Last Name

First Name

49

ASANA Age

50

Referral letter(s)Please add referral letter(s) and any assessment reports below if you have any

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