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Form library · PSY-001

Psychology new client intake

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Rules differ by state; check yours.

Psychology and counselling practices taking a first set of details and the reason for the visit.

Contact details, who referred the person, and what brings them in, in their own words. It does not copy any questionnaire. It links to two published ones, and the practitioner decides whether to use them. It is not a diagnosis.

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Psychology new client intake

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Example only. Fictional rooms: Example Psychology Rooms, Subiaco. This is an intake form, not a diagnosis.

This form is not for emergencies. If you or someone else is in danger, call 000. For support now, call Lifeline on 13 11 14.

DD/MM/YYYY

Have you seen a psychologist or counsellor before?

Your practitioner may ask you to complete a questionnaire. These two are published by their authors:

Kessler Psychological Distress Scale (K10)

Depression Anxiety Stress Scales (DASS-21)

Privacy: Example Psychology Rooms collects this information to provide your care. We may share it with the people who treat you. Read our privacy policy at example.com/privacy. Example only: the practice must write its own collection notice. See GEN-002.

Fields

  • Person

    Name, date of birth, mobile and email.

  • Referring practitioner

    Who sent them. Write Self if there is no referral.

  • What brings them in

    In their own words.

  • Seen someone before

    Yes or no.

  • Questionnaires

    Links to two published questionnaires. This form does not copy them.

  • Health information

    A tick. The practice collects the health information on the form for care.

  • Collection notice

    A line the practice writes before anyone uses the form.

  • Signature

    Signed on the phone.

Questions

Does this form include a questionnaire?

No. It links to published ones. Their authors set the terms of use, so check them before you rely on a score.

What if someone is in crisis?

The form says it is not for emergencies and shows 000 and Lifeline. Your practice may want its own wording as well.

About these templates

These templates are examples only, to help you get started. They are general information, not legal, medical, clinical or professional advice, and they may not suit your business, your profession or your state or territory.

Before you use any template, you must review and adapt it, and have it checked where needed, so it fits your services, your professional body's rules, privacy and health records laws, and the law where you operate. This matters most for consent, waiver, privacy and minors' forms. You are responsible for the forms you use and the information you collect.

To the extent the law allows, nopen gives no warranty that the templates are complete, current or fit for any purpose, and is not liable for loss arising from their use. Nothing here excludes, restricts or modifies any right or remedy you have under the Australian Consumer Law that cannot lawfully be excluded.

The templates are not endorsed by or connected with any government agency, including Services Australia, Medicare or the NDIA. Do not add government logos, the Commonwealth Coat of Arms or other official marks to them. Fields that refer to government numbers (such as a Medicare card number) are labels only.

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.