Intake Form - Adult

Enquiry 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.
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Suburb*
Phone Number*
Date of Birth*

MonthDayYear
DD/MM/YYYY
Occupation*
Where did you hear about us?*

GPFriend or Family MemberWeb SearchSocial MediaOther
GP/Medical Practice Name
Referral and Funding Source Details*

MedicareNDIS (Self-funded and Plan Managed)WorkCoverCTP (Compulsory Third Party)PrivateEmployer or Agency FundingOther
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:

MandarinTaiwaneseHindiMalayalamKannadaAfrikaans
Or comes from the following background

Is a Christian
When are you able to attend appointments? (eg., Thursday afternoon). Our practice is open Monday to Friday.
What is your preference for attending sessions?

Telehealth (Zoom)Face to FaceEither
Completing the following questions in as much detail as possible will allow us to allocate to the most suitable clinician to support your mental health.
Please describe your current concerns / reason for referring for psychology*
Have you previously received a mental health diagnosis?*

YesNo
Have you previously received psychological treatment?

YesNo
If you selected 'Yes' for the above questions, please describe (diagnosis, length of treatment etc);
Indicate your overall mood in the past two weeks*

1

2

3

4

5

6

7

8

9

10

1 is Lowest/ Worst, 10 is Highest / Best
Anxiety is a state of nervousness, worry and unease. Indicate your overall anxiety over the past two weeks.*

1

2

3

4

5

6

7

8

9

10

1 is None / Low, 10 is Extreme / High
Stress is the extent to which you feel overwhelmed or unable to cope with responsibilities/pressures. Indicate your stress over the past two weeks.

1

2

3

4

5

6

7

8

9

10

1 is None/ Low, 10 is Extreme / High
Have you ever required hospital admission for Mental Health related issues?

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

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

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

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

YesNo
Is couples or family therapy your primary concern for seeking an appointment?*

Couples TherapyFamily TherapyNo
Are you seeking a report for court or custody processes?*

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

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

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

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

YesNo
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?*

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

YesNo
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)?*

YesNo
Substance type?*
Frequency of use?*

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

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

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

YesNo
Have you received a diagnosis of a personality disorder?*

YesNo
Have you received a diagnosis of an intellectual disability?

YesNo
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.
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Enquiry Form - Adult

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