Psychology Intake Form
Who is seeking counseling?
Myself
My Child
Other
Personal Information of Counseling Person
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
School Name (If Applicable)
School Year (If Applicable)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Back
Next
Your Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Is your address same with the counseling person?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship with the counseling person
Parent
Grandparent
Carer
Friend
Other
Back
Next
Referral Information
How did you hear about us?
General Practitioner
Specialist
Family or friend
Social Media
Internet Search
Other
Referrer Name
First Name
Last Name
Referral Date
-
Month
-
Day
Year
Date
Funding Information
Mental Health Treatment Plan
Private Health Insurance
NDIS
Work Cover
Self-funded
Other
Counseling
Reason for Counseling
Abuse
Addiction
Adjustment
Ageing Concerns
Anger
Anxiety
Depression
Displacement
Eating Disorders
Family
Financial Problems
Grief & Loss
Identity
Learning Difficulties
Loneliness
Obsessive Compulsive
Panic Attacks
Parenting
Post-Traumatic Stress
Relationship
Self-Esteem
Self-Harm
Sexual Issues
Sleeping
Smoking
Stress
Suicidal Thoughts
Trauma
Weight Concerns
Work Stress
Other
Please specify any previous counseling experiences
e.g. Mental Health Treatment Plan [MHTP], Employee Assistance Program [EAP], Private
Please specify any medical/allied health services who have been/are involved
Permission is given for the psychologist to obtain and exchange appropriate written or verbal information with the following persons/agencies
Please specify any diagnoses
Please specify all medications
Please specify any other concerns
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: