top of page
bgImage

Child & Adolescent Intake Form

bgImage

We would appreciate if you could please answer the following questions so that we can understand your child's circumstances better. This will help us to link your child to the appropriate clinician and service so that they can receive the most relevant intervention and assistance. The more information you provide, the greater our ability to support you. All of the information that you provide remains confidential and protected

What is your child's name (who will be accessing the service)?*

What is your name (as parent, carer, etc)?*

Phone Contact Number*

Email Address*

You are the child's...

Select an option

Other:

Does your child have a Mental Health Care Plan/Medicare GP referral?

Select an option

Does your child have an NDIS Plan?

Select an option

My child wishes to access this service using:

Other:

Does your child have a diagnosed disability, medical condition or delayed development?

Select an option

Does your child have behaviour problems

Select an option

If so, what are the behaviour problems?

Has your child accessed any other service / intervention in the past? If so, what?

Other:

Have you attended our clinic before?

Select an option

What are your main concerns regarding your child, or why do you want to access our service?

My child would like help for:

Other:

Are there any family court/custody matters or DHHS orders/involvement?

Select an option

Are there possible or known issues of sexual abuse?

Select an option

Thank you for providing the information. Please click on the button below to submit your responses to us. We will be in contact with you as soon as an appointment time becomes available.

bgImage
bottom of page