Therapy Intake Form

Therapy Intake Form

Please complete this form to enquire about therapy services.
Contact details

We will only contact you via your preferred method.
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender
Other details
Pronouns

she/herhe/himthey/themother
Other
Preferred contact method*

EmailPhone callSMS
Phone number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

SuburbState

Post code
GP / Referral Details (if applicable)

If you have a referral, please provide details below. You do not need a referral to access therapy services, but a referral is required to receive a Medicare rebate. (You can obtain a Mental Health Treatment Plan from your GP.) Note that I am not current accepting new NDIS participants or DVA clients.
Details of referral ie GP name, number of sessions available (if applicable).
Main challenges you'd like support with:
Select all options that apply*

Understanding autism / ADHDBurnout (autistic/ADHD burnout, workplace burnout, or general exhaustion)Navigating relationships (friendships, romantic, family, workplace)Anxiety or stress (e.g., worry, social, panic, phobia)Low mood, depressionTrauma (past experiences, family or relationship difficulties, bullying, DV, medical trauma)Emotional intensity or difficulty regulating emotionsPerimenopauseCommunication or social dynamicsDifficulty starting or completing tasksChallenges with sleep, eating, or maintaining routinesSensory sensitivities or overwhelm (e.g., noise, light, textures, crowds)Shutdowns or meltdownsAdjusting to life transitions (moving, parenting, relationship ending, retirement)Chronic pain and/or illnessOther
Details
Please note:
My focus is on neuroaffirming therapy and assessment for neurodivergent adults. I’m not able to provide support where the main concern is parenting, addiction, personality disorders, OCD, eating disorders, or acute crisis care. If these are your primary needs, I can suggest other services that may be a better fit.
Mental health history
Please let me know if you have any past or current diagnoses, or if you personally identify with any of the following experiences.

AutismADHDAuDHD (Autism + ADHD)Anxiety (phobia, social, worry, panic)DepressionTraumaOCDTics / Tourette'sBipolarEating disorder (please provide details)Personality Disorder (please provide details)PsychosisSchizophreniaSubstance dependenceGambling dependenceSelf-harmOther
Details
Physical and medical conditions
Do you experience any of the following?

Chronic painChronic Fatigue Syndrome / Myalgic Encephalomyelitis (CFS/ME)FibromyalgiaReproductive and women’s health concerns (perimenopause, menstrual health, PMDD, endometriosis, Polycystic Ovary Syndrome (PCOS), fertility challenges, etc)Gastrointestinal conditions (IBS, reflux, coeliac disease, Crohn's disease, etc)MigraineEpilepsyHypermobility / Ehlers Danlos Syndrome (EDS)Sleep disorders (insomnia, sleep apnea, circadian rhythm disorders)Other medical conditions (list below)
Details
Medication
Please list medications you are prescribed and the reasons for taking.
Legal matters
Do you have any current legal matters in court? For example family law court, criminal matters. (Please note that I am not able to provide services for those with current legal matters before the court.)*

NoYes
If yes, please provide details:
What do you feel are your strengths, passions, or values that help you in life?
Further information or questions
Is there any other information you would like to provide? Any questions?
Existing reports or documents
Do you have any existing reports or documents relevant to the service you are seeking? For example, psychiatrist, psychologist, OT, speech and language therapy reports.

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How did you hear about NeuroAffirm Psychology?

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Appointment days - Thursdays and Fridays only

Therapy sessions are currently offered on Thursdays and Fridays only each week. If these days do not suit your schedule, I can provide recommendations for other clinicians who may have broader availability.
Privacy Collection Statement

NeuroAffirm Psychology values your privacy and complies with the Australian Privacy Act 1988 (Cth). We collect personal information, such as your name, email, and message, when you submit our contact form. This information is used to respond to enquiries and provide support. By submitting the form, you agree to this collection statement.
Please indicate your consent below:*

I agree to the collection and use of my personal information in accordance with the Australian Privacy Act 1998 (Cth).
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Therapy Intake Form

Contact details

GP / Referral Details (if applicable)

Main challenges you'd like support with:

Mental health history

Physical and medical conditions

Medication

Legal matters

What do you feel are your strengths, passions, or values that help you in life?

Further information or questions

Existing reports or documents

Appointment days - Thursdays and Fridays only

Privacy Collection Statement