Go With That Therapy

Name *

First NameLast Name

Name of young person

First NameLast Name

Date of Birth*

Date

Gender*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Preferred contact method:*

Is it OK to leave a voicemail or send SMS reminders to your phone?*

YesNo

Emergency contact: name*

example@example.com

Emergency contact: number*

Please enter a valid phone number.

Is anyone aware you have reached out for counselling supports?*

Briefly describe what you are seeking support with*

If you are seeking counselling for your child, please indicate:

Do you have legal custody of this child*

YesNo

Are there any parenting or court orders in place I should be aware of?*

YesNo

Is your child aware of and consenting to therapy?*

YesNo

During the past month, have you been bothered by feeling down, depressed or hopeless?*

YesNo

During the past month, have you often been bothered by little interest or pleasure in doing things?*

YesNo

Have things been so bad for you lately that you have thought you would rather not be here?*

YesNo

Has anyone in your family done something that made you or your children feel unsafe or afraid?*

YesNo

Has anyone in your family done something that made you or your children feel unsafe or afraid?*

YesNo

I understand that Go With That Therapy may need to share information with emergency contacts or services if there are concerns about my safety or the safety of other*

YesNo

Have you ever been diagnosed with a mental health condition or as neurodiverse?

YesNo

Have you experienced any trauma in childhood? This could relate to anything you feel happened when you were a child that has lasting effects today

YesNo

Have you had any type of counselling or EMDR Therapy in the past?

YesNo

If yes to the above, please describe type of counselling, treatment received and outcomes.

Has any family member been diagnosed with a mental health condition?

Please list any current prescription medications or medical concerns.

Are you planning to use NDIS, Mental Health Care Plan or private funding for appointments?

Please note appointment times are currently limited to Tuesdays and Fridays. Please advise if you have a preference for day or time.

Would you be happy to engage in online therapy?*

YesNo

Is there anything else important we should know? Preferences or Requirements?

Please indicate how you found me:*

Date

Signature

Thank you for taking the time to complete this form. We will be in contact with you shortly to arrange an initial appointment or discovery call. Please note that responses are not monitored daily.

Please note Go With That Therapy is not a crisis service. Please contact Lifeline on 13 11 14 or call 000 for emergency support.