Intake Form - Adult

We look forward to speaking with you soon. Thank you for giving us information that will help our intake team with your call. You may be eligible for a Medicare rebate with a valid referral. Our current fees can be found here. Please note that we do not offer bulk-billing at our practice.

Before we get started, a quick note about the types of support we currently offer. At this stage, we’re unable to provide support for addictions, eating disorders, family or couples counselling, court-mandated therapy, cognitive or ADHD assessments, or children who have not yet started school.

Full Name

First NameLast Name

Email

example@example.com

Phone Number

Suburb

Phone Number

Format: (000) 000-0000.

Date of Birth

DD/MM/YYYY

Occupation

Where did you hear about us?

GP/Medical Practice Name

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

When are you able to attend appointments? (eg., Thursday afternoon). Our practice is open Weekdays and Saturday Morning

What is your preference for attending sessions?

Please describe your current concerns / reason for referring for psychology

Have you previously received a mental health diagnosis?

Have you previously received psychological treatment?

If you selected 'Yes' for the above questions, please describe (diagnosis, length of treatment etc);

Indicate your overall mood in the past two weeks

Anxiety is a state of nervousness, worry and unease. Indicate your 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 stress over the past two weeks.

Have you ever required hospital admission for Mental Health related issues?

Have you required hospital admission for Mental Health related issues in the last three months?

Are you seeking psychology sessions under a work cover referral?

Are you seeking a report for employment or education related concerns?

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

At the moment, we only provide individual therapy. Are you seeking an alternate form of therapy such as couples or family therapy?

Are you seeking a report for court or custody processes?

Have you ever found out that you see or hear things that other people don't?

Have you ever experienced 'ups' where you feel so 'good' or 'hyper' that you or others don't think you are your normal self?

In the past 3 months, have you had an intense fear of gaining weight?

In the past 3 months, have you been deliberately trying to limit the amount of food you eat to influence your weight or shape?

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

In the past 3 months, did you have times when you worried you have lost control over your eating?

Are you or someone you know (e.g. family, friend, health professional) concerned about your level of alcohol consumption, or use of drugs (illegal or prescription medication for non-medical reasons)?

Substance type?

Frequency of use?

During the past year, how often have you failed to do what was normally expected of you because of your substance use?

Have there been any times in the past year that you have used an illegal drug or a prescription medication for non-medical reasons?

Is treatment for addiction (e.g. alcohol or substance use, gambling, pornography) your primary concern for seeking an appointment?

Have you received a diagnosis of a personality disorder?

Have you received a diagnosis of an intellectual disability?

Concrete Steps Introduction Video

Due to the limited availability of appointments currently, our psychologists recommend getting a head-start on therapy with our Concrete Steps program (video above). Concrete Steps is a 6-module online psychology fundamentals course, developed by our clinical team here at the Centre For Effective Living. The cost of our Concrete Steps program is less than the cost of one session with a psychologist, and can be done either beforehand or alongside therapy. Your intake counsellor will discuss Concrete Steps with you during your intake call.

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

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

Enquiry Form - Adult