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Phone Intake Form 2 – to trigger emails to clients
Parent/Callers FULL NAME
First
Last
Suburb
Mobile Number (only landline if no reception)
Email (read back to them)
Child/Children's or Adult Client's FULL NAME
First
Last
Client Age Range
Baby/Toddler
Primary school
High school
Adult
Presenting issue specifics, therapy goals and context
Main presenting issues
Anger/aggressive behaviours
Adjustment issues
Anxiety - generalised (inc OCD)
Anxiety - specific (separation, phobias)
Assessment required (with possible school observation)
Attention/ADHD issues
Autism/Aspergers
Blended family/separated family issues
Challenging behaviours (besides aggressive)
Complex client or family context
Couples/Partner Relationship Issues
Depression
Grief and Loss
Legal/Family Court proceedings occuring (informed no reports)
Parental skill building required
Technology use issues
Trauma (complex) - DV, abuse, neglect
Trauma (simple) - single incident or event
School specific (eg learning issue, task avoidance)
Social skills related
Sleep
Self-harm/Suicide Risk/high-risk clients
DAYS they want or are available for sessions
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
TIMES they want or are available for sessions to start
Before school
During school hours (am)
During school hours (pm)
After school (2.45-5.30pm)
Evening (5.30-8pm)
Day Date Time 1st session confirmed in Gcal (leave blank if time still needs to be confirmed)
Claiming type
*
Medicare - need to get MHPs to us (not paid)
Medicare - paid $50 at phone intake, need to get MHPs to us
Private Health or No Rebate (Not Paid at phone intake)
Private health or No Rebate - Paid $50 at phone intake
NDIS Client Self managed
NDIS Client Plan managed
Helping Children with Autism (HCWA) or Better Start Funding - need to provide approval letter
Medicare - want Bulk Billing, need to get MHPs to us
Allocated Psychologist
Bianca
Julie
Michaela
Rob
Steve