Intake Form Name * First Name Last Name Birth Date * MM DD YYYY Gender * Pronouns Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Occupation * Are you currently going through court or legal proceedings? * Yes No Next of Kin Full Name * Next of Kin Telephone Number * Next of Kin Email * Next of Kin Relationship With You * Therapeutic Focus Emotional Difficulties Generalised Anxiety Social Anxiety Depression Neurodiversity (e.g. ADHD, ASD) Sexuality Gender Identity Life Transitions (e.g. journey to parenthood; retirement) My Relationship with Others My Relationship with Myself Recent Relational Trauma (infidelity, abuse) Childhood Trauma or Neglect Post-Traumatic Stress Personal Growth Work and/or Carer's Burnout Loss & Grief Other Are you currently seeing a psychiatrist? * Yes No Have you previously been hospitalised for reasons related to your mental health? * Yes No Are you currently taking any medication for your mental health? * Yes No Has your GP or psychiatrist ever diagnosed you with a mental health issue? * Yes No Do you have a GP Referral / GP Letter/ Mental Health Care Plan? * Yes No Will you be seeking funding from a third party? (e.g. Private Health, Work Cover, NDIS) * Yes No Unsure Name of your referring General Practitioner (If none leave blank) Please provide their place of practice (If none leave blank) Private Health Insurance Fund (e.g. BUPA, Medibank Private) Medicare Card Number Reference (Number beside your name on the Medicare card) Medicare Expiry Date (MM/YYYY) Preferred Day for Appointments * Mondays (in person or Telehealth) Tuesday (in person or Telehealth) Please let us know if there is any other information that you think it would be helpful for Genevieve to know prior to your first appointment. How did you find out about Emotion Focused Psychology? Message sent!
