Booking Questionnaire

Booking Questionnaire

Please answer the following questions about the person seeking treatment.
Main Contact Name

PrefixFirst NameLast Name
Main Contact Person DOB

DayMonthYear
Date
Main Contact Person Age
in years
Residential Address

Street Address

Street Address Line 2

CityState

Post Code
Best Contact Number
e.g. 0412345678Format: 0000000000.
Email
example@example.com
Names, DOB & Ages of all family members participating in Family Therapy?
How did you hear about us?
Your Treatment Preferences

Please answer the following questions so that we can tailor your treatment to your needs.
Main Presenting concerns for seeking Family Therapy
Has your family participated in Family Therapy before? If yes please provide details (i.e. clinician or practise name and when last participated)
Does anybody in your family who is participating in family therapy see a Psychologist or Psychiatrist? If yes, please name clinician and state when last seen.
e.g. female only, John Smith, no preference, etc. Please view our team here: https://anxietyhouse.com.au/about/
Are there any mental health diagnosis(s) for any family members? If so please describe.
Your Availability

Please indicate your availability so that we can offer appropriate appointments.
What days suit you for appointments? *Please note after-hours (after 5pm) sessions incur a surcharge fee.
Please specify the limits to your availability, if any:
Do you understand and agree to the following?
Please note, as Anxiety House Brisbane and The OCD Clinic work in conjunction with each other, you may be contacted by either clinic regarding appointment options.

Both clinics have clinicians that treat anxiety, OCD, and several other conditions.
Should be Empty:

Your Treatment Preferences

Your Availability