Intake Form - Adult

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 you with an appointment that will suit your needs. We regret however that these appointments are quite limited.

Due to the limited availability of appointments, if you have experienced distress to the level that you are hurting yourself, thinking about hurting yourself and are in imminent danger to yourself, please exit this form, speak to your 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 you. 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 emergency or crisis attention please contact The Mental Health Line on 1800 011 511 or dial 000. The LifeLine number is 131114.

Full Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Suburb *

Phone Number *

Date of Birth *

DD/MM/YYYY

Occupation *

Where did you hear about us? *

GP Friend or Family Member Web Search Social Media Other

GP/Medical Practice Name

Please indicate your referral option

GP/Specialist Referral NDIS (Self-managed) Private Unsure Other

Do you require a therapist who speaks one of these languages:

Mandarin Taiwanese Hindi Malayalam Kannada

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

Have you previously received a mental health diagnosis? *

Yes No

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

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. *

Are you seeking psychology sessions under a work cover referral? *

Yes No

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

Yes No

Are you requiring couples or family therapy? *

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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? *

Yes No

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

Yes No

Are you or someone you know (e.g. family, friend, health professional) concerned about your level of alcohol consumption? *

Yes No

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

Yes No

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

Yes No

Have you received a diagnosis of a personality disorder? *

Yes No

Have you received a diagnosis of an intellectual disability? *

Yes No

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?

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 our intake team will be in touch shortly. Thank you.

Enquiry Form - Adult