FORM_New Client intake - Insight vs Instinct

New Client Intake

Your Practitioner*
Your Legal Name*
Prefix First Middle Last
Preferred Name
What name do you prefer to be called?
Date of Birth*
Date Format: DD slash MM slash YYYY
Your Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation (optional)
Or, what you spend most of your time doing
Relationship Status (optional)
Next of Kin
Please provide details for an emergency contact that lives closest to you and whom you trust.
Name
First Last
Phone
Email
Health / GP details
Do you have a current Referral or Mental Health Plan
- Yes, I have a Mental Health Plan
- Yes, I have another referral
- No, I will claim with my Private Health Insurance
- No, I don't need to claim a rebate.
Mental Health Plan or Psychiatrist referral allows you to claim the Medicare Rebate with Health or Allied Health Practitioners only.
GP / Doctor's Name
First Last
GP / Doctors Clinic Name & Address
Date of last visit / checkup
Date Format: MM slash DD slash YYYY
Medications currently being taken:
(please list medications taken within the past 4 weeks).
Medical Procedures
(please list any significant medical procedures you've undergone).
Type of Assistance wanted?
Please briefly outline what you're wanting help with; OR leave blank to discuss directly with your practitioner.
Consent
Privacy & disclosure*
As part of providing a mental health / health / therapeutic service to you, we will need to collect, record & retain certain personal information relevant to your case. You may view and/or request a copy of this information at any stage in writing from your practitioner (an administrative fee may be incurred). All such information will remain confidential and will not be released without written consent or permission except where it is subpoenaed by a court or required by law.
(You may also elect sign a separate authority to disclose so information can be shared with your other treating practitioners).
I agree to the privacy policy.
Feedback (optional)
I understand that positive feedback given may be posted online or on our website, and can request that it be removed or changed at any time.
I will consider providing feedback (positive or constructive) and consent to being sent a feedback form for this purpose.
Email
This field is for validation purposes and should be left unchanged.

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New Client Intake

Next of Kin

Health / GP details

Consent

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