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Western Psychological Services
Intake Form
All information provided to us will remain confidential. 
Client Details
Do you have a Healthcare Card?
Do you have a DVA/Pension Card?
Street Address:
Post Code:
Which phone number can we contact you on?
PLEASE NOTE: We will not identify ourselves when calling apart from giving our name.
We send SMS reminders 48 hours prior to appointments. Please indicate if this is ok.
Can you be contacted / correspondence be sent via email? (e.g. Invoice statements, receipts, Information sheets etc ...)
Emergency Contact Details
Only in emergency
Are you of Indiginous Australian / Torres Strait Islander descent?
List any languages other than English that are spoken by you and your family:
Were you court ordered to attend?
Are you attending for the purposes of a report to be written?
Are you attending under an employee assistence program?
Billing Department Code:
(if required)
Are you attending under an employee assistence program?
Name of your Doctor:
Is this appointment in relation to:
Employment Details
Workcover / VOCAT
(if relevant)
Transport Accident Commission (TAC) Claimants
(if relevant)
Additional Details
Who lives in the main household with you?
Number of dependent children living with you (if applicable):
Have you consulted with a counsellor/therapist previously?  
If yes, when?
How long had you been attending counselling?
Could you briefly describe what has brought you to counselling and what you are hoping to achieve from your sessions?
The following information will be discussed with your psychologist during your first appointment.
By submitting this form I agree that I have been informed of the above practice policies.
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