Copy of Intake Form | wps-psychology

Do you have a Healthcare Card?

Yes

No

Do you have a DVA/Pension Card?

Yes

No

We send SMS reminders 48 hours prior to appointments. Please indicate if this is ok.

Yes

No

Can you be contacted / correspondence be sent via email? (e.g. Invoice statements, receipts, Information sheets etc ...)

Yes

No

Are you of Indiginous Australian / Torres Strait Islander descent?

Yes

No

Were you court ordered to attend?

Yes

No

Are you attending for the purposes of a report to be written?

Yes

No

Are you attending under an employee assistence program?

Is this appointment in relation to:

Who lives in the main household with you?

Have you consulted with a counsellor/therapist previously?

Yes

No

I understand that 24 hours notice must be provided to Western Psychological Services (WPS) when cancelling an appointment or I may be charged with an $88.00 late cancellation fee.

I have been made aware of the Late Cancellation fee / Non Attendance fee policy.

Have had confidentiality and privacy policies explained or indicated where client can access this information.

WPS may release information in certain circumstances such as Court Order or danger to self or others.

Western Psychological Services

Intake Form

All information provided to us will remain confidential.

Client Details

Street Address:

Suburb:

Post Code:

Which phone number can we contact you on?

PLEASE NOTE: We will not identify ourselves when calling apart from giving our name.

Emergency Contact Details

Only in emergency

List any languages other than English that are spoken by you and your family:

Are you attending under an employee assistence program?

Billing Department Code:

(if required)

Name of your Doctor:

Phone:

Employment Details

Workcover / VOCAT

(if relevant)

Transport Accident Commission (TAC) Claimants

(if relevant)

Additional Details

Number of dependent children living with you (if applicable):

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.