• Psychiatric Initial Self Report

    Prior to your initial appointment with Dr Amit Dahiya

  • Details can be approximate, please fill as much as you can.  Please submit this form at least 1 week before your appointment.  To secure your appointment, you will need to fill in the pre-payment registration form (due to the high levels of demand this is a requirement to secure your appointment date and time).  The link to the payment registration form is at the end of this intake form.

  • Date*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Gender*

  • Social Situation

  • Current Living Arrangement*
  • Relationship Status*
  • Employment Status*
  • Qualifications

  • Presenting Problems

  • Current Severity of your Mental Health Condition
  • How do your difficulties currently affect your life

  • Current Medications

  • Psychiatric Medications
    Rows
  • Physical Health Medications/Supplements/Over the counter medication
    Rows
  • Allergies
    Rows

  • Psychiatric History

    Have you ever suffered from/been diagnosed with any of the following:
  • Indicate your history below
    Rows
  • Have you ever been hospitalised for mental health reasons*
  • Please indicate
    Rows
  • Previous Outpatient Psychiatric Treatment (please fill in all that apply)
    Rows
  • Psychiatric Medications that have been trialled in the past.
    Rows

  • Substance Use

  • Please mention amount used daily/weekly + age you started = when you last used
    Rows
  • Have you ever received support for substance use in the past*

  • Physical Health Issues

  • Please list any health issues and age when it occurred below
    Rows

  • Family History

    of psychiatric problems
  • Please list any health issues and age when it occurred below
    Rows

  • Life Chart

    Developmental History
  • Please provide details regarding significant memories & experiences at following ages • Happy memories • Difficult Memories • Trauma • Mental Health Issues • Physical Health Issues • Educational Achievements/issues • Career start/end/issues • Relationship start/end/issues • Substance use • Legal Problems • Other events*
    Rows

  • Required Medical Information

  • •  If available, please bring/email the latest set of investigations/measurements that were done by your GP or other clinicans.  You can ask your GP/clinician practice to send them directly to results@cygnetclinic.com.au or HealthLink ID: cygnetcl

     

    •  Any other relevant investigations/notes/rports from your past are also appreciated

     

    •  Please bring list of current medications and doses

  • Additional Information

    Appreciated prior to your initial appointment - A checklist of optional additional information is list below
  • Basic Measurements
  • Laboratory Tests
  • Previous Assessments
  • Additional Test Results (only if done prior for specific reasons)

  • Please note:

    •  If not available then these can be arranged at the initial consult

    •  Not all tests may be necessary

    •  Some tests may need to be repeated based on previous results

    •  Additional tests may be requested based on clinical presentation

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  • Service Agreement & Conditions

     

    Cancellation Fee

    Please inform the referred Patient of Fees, incuding a DNA.  Fees are available on cygnetclinic.com.au/psychiatricfees

     

    Emergency

    Please inform the patient that we are not an emergency service and not open after hours   If in need of counseling after hours, please contact LifeLine on 13 14 33 or an Ambulance by dialing 000.

     

    Review Process

    Ensure that the patient knows that demand for Psychiatry is overwhelming and that each referral needs to be reviewed by the Psychiatrist before being accepted and booked in. 

  • Thank you - Please Tap Submit Below

    This will save your details securely, and direct you to the pre-registration form to secure your appointment time/date.
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