Enquiry Form
Thank you for your interest in accessing services at our clinic. This form allows us to collect important information to help triage and manage enquiries for therapy and/or assessments. Please note that completing this form does not guarantee a place, but it ensures we have the information we need to review your request. Your information will be handled securely and with care, in accordance with privacy regulations. We will contact you within 7 days to book an appointment or place you on our waitlist.
General Details
Client's Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Gender
Parent/Guardian's Name (if applicable)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Referrer (if applicable)
Do you have a Mental Health Care Plan?
Yes
No
Are you currently an NDIS participant?
Yes
No
What type of support are you seeking?
Therapy or counselling – Support for emotional, behavioural, social, or mental health concerns through regular sessions with a psychologist.
Psychological assessment – A structured evaluation (e.g. cognitive, ADHD, autism, educational, diagnostic) that includes testing and a written report.
Both or I’m not sure – I need help figuring out which option is right.
Is the client under 18 years of age?
Yes
No
Have you been seen at our clinic before?
Yes
No
Therapy
Therapy
Please complete this section if you are seeking therapy or counselling services.
Presenting Concerns - Please tick the concerns that are relevant to you & the things you would like assistance with:
Anxiety
Depression
Stress
Panic / Fears / Phobias
Self-Confidence
Eating Related Concerns
Trauma Experiences
Grief & Loss
Changes in presentation
Self-harm
Suicidal Thoughts / Plans
Social Difficulties
Other
What are your goals of therapy?
Is there anything else important you would like us to know?
Assessment
Assessment
Please complete this section if you are seeking a formal assessment (e.g. cognitive, diagnostic, educational).
What type of assessment are you seeking?
Cognitive
Autism/ADHD
Educational/learning
Other
Have you had any previous assessments?
Yes
No
Are you working with a paediatrician or GP in this process?
Yes
No
What are the main reasons or concerns that have led you to seeking an assessment?
Are there currently any adjustments in school/work?
Is there anything else important you would like us to know?
Family and Legal Information (for clients under 18)
Family & Legal Context
REQUIRED FOR CHILDREN UNDER 18. As part of providing ethical and appropriate care, we ask for information about parenting arrangements, family court involvement, and consent from both parents or guardians. In accordance with professional guidelines, best practice is to obtain consent from both parents (or all legal guardians) before beginning therapy with a child. We also recognise that in some situations, this may not be possible or safe. This will be discussed with you during the initial session, including whether contacting the other parent is appropriate or safe. We are committed to working with you to navigate this respectfully, ethically, and in the best interest of the child.
Is the child currently involved in family court or legal proceedings?
Please Select
Yes
No
Prefer not to say
Not Applicable
Are the parents separated?
Please Select
Yes
No
If yes, do both parents consent to therapy?
Please Select
Yes
No
Not sure
Has the child experienced any of the following? (Check all that apply)
Domestic violence
Child protection involvement
Past trauma
Diagnosed mental health condition
Do you have any reports or supporting documents you'd like us to review?
Is there any urgency or risk we should be aware of?
Terms & Conditions
Terms & Conditions
By submitting this form, I understand that this is a request to be placed on the clinic's waitlist and does not guarantee an appointment. I consent to the information provided being used to assess suitability and manage the waitlist process. I acknowledge that therapy services for children typically require the consent of both parents or legal guardians unless there are legal exceptions, which will be discussed further at the intake or initial session. I understand that I will be contacted when an appropriate appointment becomes available and that I may be removed from the waitlist if I do not respond to follow-up contact. I confirm that all information provided is accurate to the best of my knowledge, and I agree to these terms. I consent to this form and the information provided being securely stored on file in accordance with the APS Ethical Guidelines.
Do you agree to the terms & conditions?
Yes
Submit
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