NEW CLIENT INTAKE
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Sex
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
What is your preferred way of being contacted? (select all that apply)
*
Phone
Text
Email
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Marital Status
Occuption
Religious Affiliation/Beliefs
EMERGENCY CONTACT/NEXT OF KIN
Emergency Contact
First Name
Last Name
Phone Number
your visit with me
Please briefly describe the reason for your visit with me, including how long this has been affecting you
*
Please list the struggle/s for which you are seeking help with?
Current Symptoms
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Other
Have you ever had feelings or thoughts that you didn't want to live?
*
Yes
No
Do you currently feel that you don't want to live?
*
Yes
No
Previous therapy
Have you previously had Counselling (or other therapy), Coching or Mentoring? If so, please provide some basic information about it.
Outpatient treatment
Yes
No
If yes, please describe when, by whom, and nature of treatment
Psychiatric Hospitalisation
Yes
No
If yes, please describe when, by whom, and nature of treatment
CURRENT OR Past Medications
Please list any medications you are currently taking, or any you have prevoiusly taken. Please list any negative side effects you believe they might have on you
Please list any supplements or natural products you are currently taking
Signature
*
Guardian Signature (if under age 18)
Today's Date
-
Day
-
Month
Year
Date
My Products
*
prev
next
( X )
Individual Session
One hour appointment for one person
$
110.00
AUD
Joint Session
One hour appointment for two people (eg parent and child, couple, co-parents)
$
150.00
AUD
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
THANK YOU FOR TRUSTING ME WITH YOUR MENTAL HEALTH AND WELLBEING
Print Form
Submit
Submit
Should be Empty: