General Assessment Intake Form

Date

DayMonthYear
Date
Details Form
First Name*
Last Name*
Birthdate*

DayMonthYear
Date
Gender*
Age Calculation Field
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Next Of Kin/Emergency Contact details

Provide parent/guardian or emergency contact details as required
Next Of Kin/Emergency Contact name

First NameLast Name
Next Of Kin/Emergency Contact Email
example@example.com
Next Of Kin/Emergency Contact Phone Number
Next Of Kin/Emergency Contact Address

Same as aboveAlternate address
Next Of Kin/Emergency Contact Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Psychological Service
Please detail the concerns which have prompted this referral:
e.g.: academic struggles, behavioural issues, etc. You can also add here any previous testing, diagnoses, any relevant details, etc.
File Upload

Upload any relevant files or documents here.
Cancelof
Psychological Service

As part of providing a psychological service to you, your child(ren) or family members, Healthstyles Clinic will need to collect and record personal information from you that is relevant to your current situation. This information is a necessary part of the assessment that is conducted. The assessment will be used for educational planning purposes. All personal and sensitive information will be gathered, held and released in line with the requirements of the Privacy Act 1988 (Cth) and our Privacy Policy.

You are able to request access to the information we hold on file about you. We will follow a process in line with the Privacy Act 1988 (Cth) and in line with our Privacy Policy to review the request and respond within a reasonable period. If we cannot grant access due to legal reasons, we will provide you with notice explaining why.

All personal information gathered during the provision of the psychological service will remain confidential and secure except where:
1. It is subpoenaed by a court, or
2. Failure to disclose the information would place you or another person at serious and imminent risk; or
3. Your prior approval has been obtained to
a) Provide a written report to another professional or agency, e.g. a GP or lawyer; or

b) Discuss the material with another person, e.g. a parent or employer; or if disclosure is otherwise required or authorised by law.
Permission is given for the term of treatment or until I withdraw my authority in writing. I agree to the terms of service and declare that the information I have provided is true and correct.

I have read and understand the above referral form. I agree to these conditions for the psychology service provided.
Should be Empty:

Details Form

Next Of Kin/Emergency Contact details

Psychological Service

Permission is given for the term of treatment or until I withdraw my authority in writing. I agree to the terms of service and declare that the information I have provided is true and correct.