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If you have experienced distress to the level that you are hurting yourself, thinking about hurting yourself and are in imminent danger to yourself, speak to your treating doctor and/or present at the emergency department of a hospital immediately. In an emergency dial 000 or in a mental health crisis call Mental Health Triage on 131465.

The information in this form will be used to determine whether Adelaide Psychology & Co is an appropriate service for you. If we are unable to provide you with a service it will be deleted. Your completion of this form indicates your understanding and agreement to the way we will use this information.

First Name *

Last Name *

DOB *

Phone Number *

Email Address

Briefly state the reason for seeking therapy with a psychologist *

Preferred days for appointments (Opening hours 8am - 5pm)

Psychologist preferences, e.g. gender, religious background, or preferred psychologist/s

Do you want telehealth (online) or phone only appointments?

YesNo

Are you involved in any legal proceedings (e.g. family court) or likely to be?

YesNo

If yes, please outline court proceedings:

Do you have a referral from a GP, paediatrician or psychiatrist?You need a referral to be eligible for Medicare Rebate. Not having a referral may also impact your ability to claim for inpatient services from both Medicare and Private Health Insurers.

You may upload your Referral here.

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