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. 0412345678
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.*

TuesdayWednesdayThursdayFridayNo preference
Please specify the limits to your availability, if any:
Do you understand and agree to the following?*

I understand that Anxiety House is a full fee clinic and does not bulk bill.I understand that I may be placed on a waiting list for an initial appointment.I understand that Family Therapy is different to Couples Counselling.In some cases, Family Therapy can be covered under a Mental Health Care Plan for the individual with the presenting concerns. Please discuss this with your therapist and GP.
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