Intake Form
Child's Details
First Name
*
Surname
*
D.O.B
*
Gender
*
Male
Female
Other
Phone Number
*
Email
*
Street Address
*
Suburb
*
State
*
NSW
ACT
VIC
SA
WA
NT
QLD
TAS
Postcode
*
Is the child in out of home care?
Yes
No
Family Details
Parent/Legal Guardian 1
First Name
*
Surname
*
Phone Number
*
Email
*
Parent/Legal Guardian 2
First Name
Surname
Phone Number
Email
Parent/Guardian Relationship
*
Married
Defacto
Separated
Are there court orders in place?
*
Yes
No
Child lives with
*
Parent/Guardian 1
Parent/Guardian 2
Both
Funds
Please choose one
*
Medicare
NDIS
Private Health Fund
Child's Medicare Number
*
Child's Medicare Reference #
*
Expiry
*
Parent's Medicare Number
*
Parent's Medicare Reference #
*
Expiry
*
NDIS Funding
*
Plan Managed
Self Managed
Plan Manager
*
Reason for Referral
Please Select up to 3 of the following reasons for seeking psychological services:
*
Anger issues
Anxiety
Autism
Behavioural issues
Depression
Eating disorders
Grief & loss
Inattention/impulsivity
Learning difficulties
Obsessive/compulsive
Panic attacks
Phobia
School refusal
Self-esteem
Self-harm
Sleeping issues
Social skills
Suicidal thoughts
Toileting issues
Trauma
How did you hear about us?
*
General Practitioner
Specialist
Allied Health Practitioner
Family/Friend
Social Media
School
Internet Search
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