Personal Information:

First name:

Last name:

Birthday:

Day

Month

Year

Gender:

Phone

Email:

Emergency Contact:

Background Information:

What are your primary reasons for requesting an appointment with Sarah?

Have you previously participated in any therapy or counselling? If yes, please provide details (type of therapy, duration, etc.).

Have you ever been diagnosed with a mental health condition? If yes, please specify the diagnosis and treatment received.

Have you experienced any significant trauma or life events that you feel are relevant to share?

Are you currently taking any medication? If yes, please list them and the conditions they are prescribed for.

Do you have any history of substance abuse? If yes, please provide details (substances used, duration, treatment received).

Medical History:

Do you have a mental health care plan from your GP? You will need this if you wish to claim the medicare rebate.

Please Upload your MHCP here.

Do you have any medical conditions that we should be aware of? Please provide details

Do you have private health insurance? Please provide details.

Mental Health Information:

On a scale of 1 to 10, how would you rate your current level of stress or anxiety?

Have you experienced any recent changes in mood, behavior, or thoughts that concern you?

Are you currently experiencing any thoughts of self-harm or suicide? If yes, please provide details.

Do you have a support system in place (family, friends, support groups)? Please describe.

Additional Information:

How did you hear about working with Sarah?

Are you aware that Sarah's sessions are $230 for a 50 minute session? Medicare and health fund rebates are available to eligible clients.

Sarah is currently taking clients on Wednesdays and Thursdays between 8:30 AM and 3:00 PM (AEDT). Would these days work for you? If so, do you have a preferred appointment time within this window?

Consent and Acknowledgment:

I consent to my information being processed by admin and to be contacted in regards to ongoign appointments with Sarah

I acknowledge that I have provided accurate and complete information to the best of my knowledge.

Signature

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