New Patient Form
Who is seeking counseling?
Myself
My Child
Other
Information of Person Seeking Counseling
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
School Name (If Applicable)
School Year (If Applicable)
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is your address the same as person seeking counseling?
Yes
No
Relationship with person seeking counseling
Parent
Grandparent
Caregiver
Friend
Other
Referral Information
How did you hear about us?
General Practitioner
Specialist
Family or Friend
Internet Search
Social Media
Other
Referrer Name
First Name
Last Name
Referral Date
-
Month
-
Day
Year
Date
Funding Information
Funding Information
*
Mental Health Treatment Plan
Private Health Insurance
NDIS
Self-Funded
Other
Insurance Name
*
Insurance Member ID
*
Counseling Information
Reason For Counseling
Abuse
Addiction
Adjustment
Ageing Concerns
Anger
Anxiety
Depression
Displacement
Eating Disorders
Family
Financial Problems
Grief & Loss
Identity
Learning Difficulties
Loneliness
Obsessive Compulsive
Panic Attacks
Parenting
Post-Traumatic Stress
Relationship
Self-Esteem
Self-Harm
Sexual Issues
Sleeping
Smoking
Stress
Suicidal Thoughts
Trauma
Weight Concerns
Work Stress
Other
Please specify any previous counseling experiences
Please specify any medical/allied health services who have been/are involved
Permission is given for the psychologist to obtain and exchange appropriate written or verbal information with the following persons/agencies (please list)
Please specify any diagnoses
Please specify all medications
Please specify any other concerns
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: