NEW CLIENT FORM

We would love to support you in your wellness journey, please complete the form below to get in touch with us.

Please fill in the details below and a member of our Intake team will contact you within 2-3 business days.

Client name *

First

Last

Client date of birth *

Your name and relationship to the client

Only complete the above box if you are enquiring on behalf of someone else

Email *

Phone number *

Address *

I have a current Mental Health Care Plan from my GP *

Yes
No
I will get one before my first appointment

Please list the reason/s for wanting to see a clinician at this practice *

This is a reminder that Mind Psychology is not an emergency service. In the event of a mental health emergency, please contact your GP or nearest emergency department/hospital. The following services may also be of benefit in a crisis situation: Lifeline 13 11 14, Beyond Blue 1300 22 4636, Kids Helpline 1800 55 1800

Are you court-mandated, currently involved in the court system or have any legal issues pending? *

*Please note that we are unable to complete any court reports.

If you answered yes, please provide details below:

For admin use only

NEW CLIENT FORM

26 Freelands Drive Burnside
Heights VIC 3023

0401 346 099

info@mindpsychology.net

NEW CLIENT FORM

26 Freelands Drive BurnsideHeights VIC 3023

0401 346 099

info@mindpsychology.net

26 Freelands Drive Burnside
Heights VIC 3023