Western Psychological Services
Intake Form
All information provided to us will remain confidential.
Client Details
Do you have a Healthcare Card?
Yes
No
Do you have a DVA/Pension Card?
Yes
No
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.
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
Emergency Contact Details
Only in emergency
Are you of Indiginous Australian / Torres Strait Islander descent?
Yes
No
List any languages other than English that are spoken by you and your family:
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?
Billing Department Code:
(if required)
Are you attending under an employee assistence program?
Doctor
Friend
Family
Internet
Directory
Other (Please Specify)
Name of your Doctor:
Phone:
Is this appointment in relation to:
Dep. Health Human Services
Corrections
TAC/Work Cover
VOCAT
Unemployment Agency
None of the above
Employment Details
Workcover / VOCAT
(if relevant)
Transport Accident Commission (TAC) Claimants
(if relevant)
Additional Details
Who lives in the main household with you?
Living with Partner/Spouse
Living in Shared Household
Living with Parents/Family/Children
Living Alone
Other (Please Specify)
Number of dependent children living with you (if applicable):
Have you consulted with a counsellor/therapist previously?
Yes
No
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.
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.
By submitting this form I agree that I have been informed of the above practice policies.
Submit
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