Intake Form - Child (DRAFT)

We understand that it can be quite difficult to get an appointment with a psychologist at the moment. The Centre for Effective Living has a process in place to provide your child with an appointment that will suit their needs. We regret however that these appointments are quite limited.

Due to the limited availability of appointments, if your child has experienced distress to the level that they are hurting themselves, thinking about hurting themselves or are in imminent danger to themselves, please exit this form, speak to their treating doctor and/or present at the emergency department of a hospital.

The information in this form will be used to determine whether Centre For Effective Living is an appropriate service for your child. The information in this form will be converted to a client file if we are able to provide you with a service. Otherwise, it will be deleted. Your completion of this form indicates your understanding and agreement to the way we will use this information.

If you require urgent attention, please contact The Mental Health Line on 1800 011 511 or dial 000. The LifeLine number is 131114.

Our fees range from $215 to 275 for a Psychologist appointment, and $260 to $330 for a Clinical Psychologist appointment. Click here to view our fee schedule.

You may be eligible for a Medicare rebate of $137.05 (Clinical Psychologist) or $93.35 (Psychologist) with a valid referral.

Some Private Health Funds cover psychology sessions. Please check with your fund if applicable.

Please note that we do not offer bulk-billing at our practice.

Child's Full Name*

First NameLast Name

Parent/Guardian Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Suburb*

Grade at School*

Date of Birth*

DD/YY/YYYY

Where did you hear about us?*

Completing the following questions in as much detail as possible will allow us to allocate to the most suitable clinician to support your child's mental health.

Please briefly describe your current concerns for your child / reason for referring for psychology *

Has your child received a previous mental health diagnosis?*

YesNo

If you selected 'Yes' for the option above, please describe;

Is your child currently taking any medications to manage their mental health concerns? If yes, describe below;

Referral and Funding Source Details*

Our clinicians come from diverse backgrounds and beliefs and are highly skilled in working with clients from different cultural backgrounds. If you have preference for a psychologist who shares a particular language or worldview we will do our best to accomodate this depending on clinician availability.

Please select from the questions below if this is applicable to you.

Do you require a clinician who speaks any of the following languages:

Or comes from the following background:

Is a Christian

When is your child able to attend appointments? (eg., Thursday afternoon). Our practice is open Monday to Friday.

Indicate your child's overall mood in the past two weeks*

Anxiety is a state of nervousness, worry and unease. Indicate your child's overall anxiety over the past two weeks.*

Stress is the extent to which you feel overwhelmed or unable to cope with responsibilities/pressures. Indicate your child's overall stress over the past two weeks.*

Are you seeking an appointment specifically for a psychometric assessment for your child? E.g. cognitive assessment, assessment of ADHD, Autism etc.*

YesNo

Are you seeking family therapy interventions?*

YesNo

Are you requiring a report for court or custody processes?*

YesNo

Has your child ever found that they see or hear things that other people don't?*

YesNo

In the past 3 months, has your child had an intense fear of gaining weight?*

YesNo

In the past 3 months, has your child been deliberately trying to limit the amount of food they eat to influence their weight or shape?*

YesNo

In the past 3 months, has your child ever used any of the following methods to control their weight: excessive exercise, making themself throw up, laxatives or diuretics, fasting for 8+ waking hours?*

YesNo

In the past 3 months, did your child have times when they ate a very large amount of food until uncomfortably full, and worried they have lost control over their eating?*

YesNo

Has your child received frequent detentions at school?*

YesNo

Does your child have a history of suspensions at school?*

YesNo

Does your child show truancy behaviour at school?*

YesNo

Does your child run away from home?*

YesNo

Is your child aggressive towards others? E.g. at home, school, etc.*

YesNo

Do you have concerns regarding your child's alcohol consumption?*

YesNo

Do you have concerns regarding your child's use of cigarettes or vaping?*

YesNo

Do you have concerns regarding your child's exposure to or use of other drugs?*

YesNo

Do you have concerns relating to your child's sexual activity?*

YesNo

If you said YES to any of the behaviours above, is this the main reason you are seeking support for your child?*

YesNo

Has your child received a developmental diagnosis? E.g. Autism, Intellectual Disability, ADHD, etc.*

YesNo

If you said YES to the above, is this the main reason you are seeking support for your child?*

YesNo

Is there any other information you would like us to know related to your enquiry?

You may be eligible for a Medicare rebate with a valid referral. For an overview of our practitioners fees, click here. Please note that we do not offer bulk-billing at our practice.

Thank you for completing this form. Please click 'submit' below, and a member of our intake team will be in touch shortly. Thank you.

Enquiry Form - Child