NEW CLIENT INTAKE FORM

Welcome to Jon Grainger Psychology.

This form collects background and contact information to help your psychologist prepare for your first appointment.

It does not replace our Consent & Authorisation Form, which you'll also be asked to complete.

Is the Client an Adult or a Child *

Adult (18 Years or older)Child or Young Person (under 18 years)

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

Prefix

Residential Address *

Is your Postal Address the same as your Residential Address? *

YesNo

Mobile Number *

Home Phone

Email Address

PARENT/GUARDIAN DETAILS (for Child Clients)

Parent/Guardian 1 Full Name

Relationship to Child

Parent/Guardian 1 Mobile Number

Parent/Guardian 1 Email

Are you a Legal Guardian?

Yes No

If No, please provide details

Upload Any Parenting or Court Orders

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Would you like to add a Second Parent/Guardian

YesNo

Parent/Guardian 2 Full Name

Relationship to Child

Parent/Guardian 2 Mobile Number

Parent/Guardian 2 Email

EMERGENCY CONTACT

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Mobile Number *

In case of serious safety concerns, do you consent to us contacting your nominated emergency contact?

FUNDING & REFERRAL DETAILS

PLEASE NOTE: We are are a Private Practice and not able to offer Bulk Billed Sessions. There is a fee unless you have approval from a Third Party to fund your treatment (eg: NDIS, SIRA, CTP, Lifetime Care & Support, DVA, EAP)

Please Specify

I understand that the full session fee (between $215 and $250 depending on my clinician’s fee) is payable on the day of my appointment. If I have provided a valid Mental Health Treatment Plan and referral, a Medicare rebate will be submitted to Medicare for processing on my behalf after payment and paid directly to my nominated bank account by Medicare. *

Medicare Number *Full Fee is paid on day (between $215 - $250 depending on the Clinician you see) - Medicare Rebate processed overnight. We have reached our Bulk Billing allocation and unable to offer to our clients.

IRN *

Medicare Number & Date of Birth ParentThis is required to ensure the Medicare Rebate can be processed and directed to the Bank Account listed on the Medicare Card

GP Name *

GP Practice Name

Do you have a current Mental Health Treatment Plan? *

YesNoUnsure

Upload Referral (optional)

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NDIS Number *

NDIS Plan Start Date *

NDIS Plan End Date *

How is your Plan Managed *

Plan ManagedSelf ManagedAgency Managed

Upload your latest Plan

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I understand that where sessions are funded through my NDIS Plan, invoices will be issued to the NDIA, my Plan Manager or to me for payment from my NDIS plan funds. If payment is declined, delayed, or unavailable through my NDIS funding, I accept responsibility for payment of the outstanding account. *

Plan Manager Organisation Name *

Plan Manager Email

Plan Manager Phone

Who should invoices be addressed to? *

Insurer Name *

Claim Number

Case Manager Name

Case Manager Phone

Case Manager Email

Attach Approval Document

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Employer Name (Optional)

Where my sessions are funded by an insurer or third party, invoices will be issued directly to the insurer subject to approval. If approval is not granted, is withdrawn, or payment is not received from the insurer, I understand that the outstanding account remains my responsibility to pay. *

Insurer Name *

Claim Number

Case Manager Name

Case Manager Phone

Case Manager Email

Where my sessions are funded by an insurer or third party, invoices will be issued directly to the insurer subject to approval. If approval is not granted, is withdrawn, or payment is not received from the insurer, I understand that the outstanding account remains my responsibility to pay. *

Attach Approval Document

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DVA Number *

DVA Card Type *

EAP Organisation *

EAP Contact (Name)

EAP Contact Phone

EAP Contact Email

Sessions Approved

Where my sessions are funded by an insurer or third party (e.g. Workers Compensation, CTP, EAP), invoices will be issued directly to the insurer subject to approval. If approval is not granted, is withdrawn, or payment is not received from the insurer, I understand that the outstanding account remains my responsibility to pay. *

PRESENTING ISSUES & GOALS

What brings you (or your child) to therapy?

Comments

When did these concerns begin?

What would you like to achieve from therapy or assessment?

MEDICAL & MENTAL HEALTH HISTORY

Do you have any diagnosed medical or mental health conditions

YesNo

Please provide details

Are you currently taking any medications?

YesNo

Please list medications

Have you received psychological therapy before?

YesNo

Please provide any details you think are relevant

School Name

Year Level

Teacher/Learning Support Contact (Optional)

What does your Child's teacher say about them?

Is your child participating in any special education programs/learning support at school?

YesNo

If yes, please describe

Has your child ever had to repeat a grade?

Other School attended (including Pre School)

Please detail

What behaviours are occurring with greater frequency or intensity than you would like?

What would you like to see happening more often?

What are your child's strengths?

What are some of the things that are currently stressful to your child and his/her family?

Are there any functional difficulties you would like us to be aware of?

What Supports to you currently have in place?

Do you require any accessibility accommodations

Yes No

Please describe any accommodations you may need

Are there any cultural, identity or faith-related factors you would like us to know about? (optional)

Anything else you would like your psychologist to know about before your first appointment?

Upload any relevant reports or assessments (optional)

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I confirm the information provided is accurate *

I understand that a consultation fee will apply unless my appointment is covered by an approved third-party funding arrangement (e.g., NDIS plan funding or a SIRA-managed insurance claim).

Please review our Fee Schedule if you are uncertain of the fee applicable
https://www.jgpsychology.com.au/fees.html *

I understand that a cancellation fee will apply in the event of a short notice cancellation (ie: less than 48 business hours notice) and the next appointment will be booked once account finalised. *

Name of Person Completing the Form *

Signature *

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Date *

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