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Client Intake

Form

Please complete the form below to get started

Private and confidential

CLIENT DETAILS:

First name*

Last name*

Preferred name

Date of birth*

Day

Month

Year

Pronouns

Address*

Mobile number*

Email*

Cultural background / considerations

Other considerations

Medicare Number*

Position No:*

Expiry date:*

Day

Month

Year

General practitioner name:*

Do you have a Medicare referral / GP letter / Mental Health Treatment Plan (yes / no / unsure)*

Are you currently seeing a psychiatrist?

Yes

No

Have you ever been hospitalised for mental health reasons?

Yes

No

Referring doctor (if applicable):

Date of referral:

Day

Month

Year

NDIS (if applicable):

Reference number:

Managed by:

Agency

Plan

Self-managed

Plan start date:

Day

Month

Year

Plan end date:

Day

Month

Year

Do you identify as Aboriginal?

Yes

No

Do you identify as Torres Strait Islander?

Yes

No

How did you hear about Equinox psychotherapy?*

Main reason you are seeking therapy*

I have read and understand the information on payment and cancellation policy provided via email, and agree to paying the standard fee for the first session unless I provide at least two business days’ notice of cancellation

I understand that Equinox does not provide crisis services or immediate appointments. For urgent help, contact 000 or crisis support services listed here

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Email*

I want to subscribe to your mailing list.

0436 804 714

naomi@equinoxbalance.com.au

PRIVACY POLICY

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