Client Information

Welcome!

I look forward to receiving your information. PLEASE READ THE FOLLOWING CAREFULLY.

This information will help your psychologist to understand you better.

When you have completed this form you will be diverted to another page to complete the DASS 42 which is a survey of symptoms of depression, anxiety and stress.

NB: Please remember that if your computer crashes, the information will be lost so you may copy the questions into a separate document and then copy and paste your answers into the form later.

You will not be able to save this form, so plan to complete it in one go.

When you have submitted the form, a message appears at the bottom of the page confirming your form has been sent.

WHAT’S A STANDARD DRINK?

A standard drink is defined as one that contains 10 grams of pure alcohol and different alcoholic drinks contain different amounts of pure alcohol.

For example, each of the drinks below are equal to approximately one standard drink.

• Two 285 ml pots/middies/schooners/handles of light beer (2.7 per cent Alc./Vol)
• One 375 ml stubby of mid strength beer (3.5 per cent Alc./Vol)
• Three-quarters of a 375 ml stubby of full strength beer (4.9 per cent Alc./Vol)
• One 285 ml pot/middy/schooner/handle of full strength beer (4.9 per cent Alc./Vol)
• 100 ml of wine (12 per cent Alc./Vol)
• Two-thirds of a 330 ml bottle of alcoholic soda (5.5 per cent Alc./Vol)
• 30 ml of spirit or liqueur (40 per cent Alc./Vol)

From: http://www.mydr.com.au/addictions/standard-drinks

Contact Form

* Denotes required field to be completed

First Name:

Last Name:

E-Mail Address:

1. Preferred Address for Invoice, Correspondence or Health Fund purposes including Suburb and Postal Code:

2. Mobile or Telephone preference and only numbers are accepted:

3. Date of Birth for example 23/07/1989:

4. What challenges you? You may select more than one:

Addictions
Anxiety
Can't Switch Off
Career
Carer
Children or Adolescents
Children or Adolescents and Parenting
Confidence
Depression
Eating Disorder
Fears and Phobias
Feeling Stuck
Overweight
Pain Management
Performance Anxiety
Post-Traumatic Stress Disorder (PTSD)
Relationship or lack thereof
Self limiting Beliefs
Separation or Divorce
Sport Improvement
Stress

5. Please elaborate on your most pressing issue. When it started? What you think caused it? What stops you from solving it? What do you think eases the problem? What could you do that you haven't?

6. Check the box or boxes for your preference for therapy:

Hypnosis
NLP
Psychotherapy
Play Therapy
Cognitive Behavioural Therapy
Mindfulness Meditation
Timeline Therapy for fears or phobias or restoring emotional balance
Overseas retreats

7. Relationship status and satisfaction with your partner if you have one:

8. Brief information about your family and relationship with them, and how it affects you:

9. Is this consultation connected to a Workcover or Insurance claim? If yes please explain and if not enter NA for not applicable.

10. Select the Health and Wellbeing factors you regularly practise:

I drink 2 to 3l water daily
Daily I drink 2 or less cups caffeinated drinks of any description
I get 30 minutes daily exercise of any description including walking
I practise daily meditation
I eat 3-5 healthy meals daily
1 drink 2 or less standard drinks of alcohol 4 days or less or not at all in a week
I enjoy a hobby at least once a week
I laugh daily
I have friends and or family who support me

11. Rate your commitment to improved mental health and well-being out of 10, where 10 is most committed and 0 is least.

12. Select the option that best fits for how you found this website:

Google
Yahoo
Bing
Other internet search engine
Print or Radio media
GP referral
Word-of-mouth
Facebook
Linked In
Twitter

^{We loathe spam as much as you do. Captcha Code prevents spam-bots from completing this form.}

Powered by Fast Secure Contact Form