NEW CLIENT INTAKE

NEW CLIENT INTAKE
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Sex*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What is your preferred way of being contacted? (select all that apply)*

PhoneTextEmail
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Marital Status
Occuption
Religious Affiliation/Beliefs
EMERGENCY CONTACT/NEXT OF KIN
Emergency Contact

First NameLast 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 moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncrease risky behaviorAvoidanceLoss of interestIncreased libidoHallucinationsConcentration/forgetfulnessDecrease need for sleepSuspiciousnessChange in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spellsDecreased libidoOther
Have you ever had feelings or thoughts that you didn't want to live?*

YesNo
Do you currently feel that you don't want to live?*

YesNo
Previous therapy
Have you previously had Counselling (or other therapy), Coching or Mentoring? If so, please provide some basic information about it.
Outpatient treatment

YesNo
If yes, please describe when, by whom, and nature of treatment
Psychiatric Hospitalisation

YesNo
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*

Powered by Jotform SignClear
Guardian Signature (if under age 18)

Powered by Jotform SignClear
Today's Date

DayMonthYear
Date

My Products*

Individual Session

One hour appointment for one person

$110.00AUD

Joint Session

One hour appointment for two people (eg parent and child, couple, co-parents)

$150.00AUD

Total

$0.00AUD

Payment Methods

Credit Card

Apple Pay

Afterpay

THANK YOU FOR TRUSTING ME WITH YOUR MENTAL HEALTH AND WELLBEING
Should be Empty:

NEW CLIENT INTAKE

EMERGENCY CONTACT/NEXT OF KIN

your visit with me

Previous therapy

CURRENT OR Past Medications

Payment Methods

THANK YOU FOR TRUSTING ME WITH YOUR MENTAL HEALTH AND WELLBEING