Intake Form - Directions Psychologists

1

Who was kind enough to suggest you see us?

Who is filling in this form today?

I'm the client — filling this in for myself I'm filling this in on behalf of someone (e.g. my child)

How did you find us?

Personal Referral School / Teacher Doctor Paediatrician Allied Therapist

2

What concerns you most right now?

3

What are you hoping we can help with?

2

Let's get to know you

First Name *

Last Name *

Date of Birth *

Sex *

Male Female Other

3

Your family & how we can reach you

Mother / Guardian

Full Name

Mobile

Phone

Email

Address

Postal Address Same as address above

Occupation

Father / Guardian

Full Name

Same contact details as Mother / Guardian above

Mobile

Phone

Email

Address

Postal Address Same as address above

Occupation

Additional Contacts

Alternative Contact Person (Name & Number)

Emergency Contact 1 (Name & Number)

Marital Status of Parents

4

Your NDIS details

Advocate / Representative (if applicable)

Full Name

Relationship

Mobile

Phone

Email

Website

Address

Postal Address

NDIS Funding Information

Is this a transition from another provider?

Yes No

Start Date of NDIS Plan

End Date of NDIS Plan

Funding Type *

Plan Managed NDIA Managed Self-Managed Other

Please Specify

Plan Review Date

Contact Details for Invoices (if applicable)

Full Name

Contact Number

Email

Communication Preferences

Language

Preferred Language Spoken

Interpreter Required?

Yes No

Preferred Method of Communication

Face to Face Phone Call Text Message Email Letter Visual (images/videos) Contact with Advocate

Engagement Preferences

Who the participant wants to engage with:

TypeWith WhomHowHow Often

5

Insurance & Medicare

Health Fund

Do you wish to claim from your Health Fund?

Yes No

Fund Name

Membership Number

GP Mental Health Care Plan

Do you wish to claim from your GP Mental Health Care Plan?

Yes No

Plan Start Date

Number of Consultations

Plan Review Date

Contact Details for Invoices

6

Your healthcare team

General Practitioner (GP)

Name

Practice Name

Phone

Email

Address

Specialists (e.g. Paediatrician, Psychiatrist, OT, Speech)

Type of Specialist

Name

Practice Name

Phone

Email

Address

7

A little more about you

Diversity & Cultural Background

Country of Birth

Indigenous Status

Aboriginal Torres Strait Islander Both Neither

Refugee / Asylum Seeker Status

Refugee Asylum Seeker Neither

Religion (if required)

Family Data

Brothers

Sisters

Parents' Primary Interests & Accomplishments

Mother

Father

8

School & interests

Current Education

School

Grade

Teacher

Principal

History of Schools Attended

Extracurricular Activities

9

Health background

Medication History

Illness History

Assessments

Has vision been assessed?

Yes No

Professional

Date of assessment

Comments

If you have a copy of the report, please email it to reception or hand it in at the front desk.

Has hearing been assessed?

Yes No

Professional

Date of assessment

Comments

If you have a copy of the report, please email it to reception or hand it in at the front desk.

Other types of screening, testing or investigation?

Yes No

Professional

Date of assessment

Comments

If you have a copy of the report, please email it to reception or hand it in at the front desk.

10

What makes you shine

Tell us about the things that make you unique.

Strengths

Hopes & dreams

Things they love

Things they'd rather skip

11

Parental Permission

Name of Child / Young Adult

Parent / Guardian 1

Name

Relationship

Telephone

Signature

Parent / Guardian 2 (if applicable)

Name

Relationship

Telephone

Signature

Only one parent providing consent (single parent responsibility)

I hereby accept the full responsibility for providing consent for consultations with a Psychologist.

Name

Signature

Separated / Divorced Parents

Where does child/young adult reside?

Contact arrangements for child/young adult?

Agreements made by:

Informal Agreement Interim Order Consent Order Parenting Plan Other

Other (please specify)

Any current proceedings before the Family Court or Children's Court?

Yes No

Please specify

12

Our fees

Here's an overview of our consultation fees. If you have any questions, our reception team is happy to help.

Initial Consultation / Assessment	$340.00
Individual / Family Consultation	$230.00
Weekend / Public Holidays / After Hours	$250.00
Group Session	$95.00
Longer Group Session	$150.00
Phone Calls (per 10 mins)	$75.00
Specialist Reports (per hour + GST)	$260.00
Parental / School Reports (+ GST)	$260.00
School Consultation / Visitation (per hour)	$240.00
Non-Payment Administration Fee	$20.00

Payment is required on the day of consultation. Non-payment incurs an administration fee.

Cancellations within 48 hours prior to an appointment will attract a cancellation fee of the cost of the session.

I've read and understood the fee schedule above

Signature

13

A quick note about Heidi

I'm happy for Heidi to be used during our sessions

Name

Date

Signature *

14

You're almost done!

Here's a quick summary. Don't worry if something's not perfect — we can always update it together later.

I confirm that the above information is accurate to the best of my knowledge, and I'm happy for it to be stored securely in line with the Australian Privacy Act 1988.

Signature

Who was kind enough to suggest you see us?

What concerns you most right now?

What are you hoping we can help with?

Let's get to know you

Your family & how we can reach you

Your NDIS details

Insurance & Medicare

Your healthcare team

A little more about you

School & interests

Health background

What makes you shine

Parental Permission

Parental Permission for Children / Young Adults to Attend Consultations

Our fees

A quick note about Heidi

How we take notes during your session

You're almost done!