Adult New Client Form

Client Information

Please complete the below 'New Client Form' to the best of your ability. If you have any questions regarding anything mentioned in this form, please contact NeuroKids & Beyond for assistance.

First Name: *

Last Name: *

Date of Birth: *

Gender: *

MaleFemaleOther

Email Address: *

Residential Address: *

Town *

Postcode: *

Phone Number: *

Emergency Contact Name and Number: *

Are you of Aboriginal or Torres Strait Islander origin?

If funded by NDIS, please state your NDIS Number:

Do you agree to NKB receiving a copy of your NDIS Plan

Yes No

If yes, please email your plan to: reception@neurokidsandbeyond.com.au

Medicare details

Card number:

Number client is on the card:

Card expiry date:

Referral Details

Who referred you to our practice? *Please include full name/s

What Service do you need? *

Why were you referred to our practice? *

Are you funded by NDIS or a third party (Anglicare, DFFH)? *

If you are funded by a third party, please state the name & email address for us to invoice: *

Family Medical and Psychiatric History

Your Mother:

Please complete the below information about your mother.

Mothers Highest Level of Education:

Does your mother have any health problems?

Does your mother have any psychiatric problems?

Your Father:

Please complete the below information about your father.

Fathers Highest Level of Education:

Does your father have any health problems?

Does your father have any psychiatric problems?

Your Siblings:

Please complete the below information about any siblings.

Siblings Highest Level of Education:

Do any siblings have any health problems?

Do any siblings have any psychiatric problems?

Extended Family:

Please complete the below information about your extended family.

If yes, please explain:

Developmental History

Where were you born? *

Were there any complications with your birth? *

Did you have any delays in learning to walk/talk/read/toilet train? If so, please explain: *

Where did you grow up? *

Has there been any recent change of locations?

Academic History

Were you required to repeat a grade in school? *

Yes No

Did you receive special education? *

Yes No

Did you graduate high school? *

Yes No

If no, what is your highest level of education?

Did you attend university? *

Yes No

If so, what degree?

Employment History

What did you do for your longest job/career? *

When did you last work? *

Are you retired? *

YesNo

Have you had any performance problems at work? *

Are you planning on applying for disability funding? *

Yes No

Marital/Relationship Status

How many times have you been married? *

Are you currently married? *

YesNo

If yes, how many years have you been married to your spouse?

What is your spouses name?

What is your spouses occupation?

Does your spouse have any health/psychiatric concerns?

Do you have any children? *

Yes No

If yes, please list their name/s and age/s

Do any of your children have any health/psychiatric concerns?

Do you feel that you have adequate family/social support? *

Yes No

Who is currently living with you? *

Is this evaluation in relation to any ongoing law suit? *

YesNo

Medical History

Do you have any other medical conditions?

Have you had any prior hospitalizations? *

Yes No

Have you ever had a serious head injury? If so, did you lose consciousness?

Do you regularly exercise? If so, how often? *

If so when was your most recent scan?

Are you currently on any medication?

If yes, when, where and by who?

Substance Use/Abuse/Dependance

Do you use cigarettes/tobacco?

Do you drink alcohol?

Do you use any illicit drugs?

Do you consume caffeine?

Current Concerns

Have you noticed any problems in your thinking abilities? *

Have they become better, worse, or stayed the same?

Have any of your friends or family members noticed changes? *

Have you noticed any changes to your mood? *

Have you noticed any changes to your personality?

Have you ever been hospitalized for a psychiatric reason?

Have you ever seen a psychiatrist? *

YesNo

Do you currently see a psychiatrist? *

YesNo

Have you ever seen a psychologist/therapist? *

YesNo

Do you currently see a psychologist/therapist? *

YesNo

How has your overall mood been? *

Is there any other information you would like to share?

Please tick any Social Groups you would be interested to attend

Adult Gamers GroupChild Gamers GroupMusic GroupArt Group

Consent

As part of providing a psychology therapy/assessment services to you, NeuroKids & Beyond needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information.

This collection of personal information will be a necessary part of the assessment and treatment that is conducted.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment is kept securely and, in the interests of your privacy, used only by Neurokids & Beyond, and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables Neurokids & Beyond to provide a relevant and informed service to you.

Consequence of not providing personal information

If you do not wish for your personal information to be collected in a way anticipated by this letter or the Privacy Policy, Neurokids & Beyond may not be in a position to provide the service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for Neurokids & Beyond to deal with you or if Neurokids & Beyond is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym, however if the Neurokids & Beyond agrees to you being anonymous or using a pseudonym, you must pay consultation fees at the time of the appointment.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. Neurokids & Beyond may discuss with your different possible forms of access.

Disclosure of personal information

All personal information gathered by Neurokids & Beyond during the provision of the service will not be disclosed except when:

1. it is subpoenaed by a court; or

a) failure to disclose the information would in the reasonable belief of the Neurokids & Beyond place you or another person at serious risk to life, health or safety; or

2. your prior approval has been obtained to

a) provide a written report to another professional or agency. e.g., a GP or a lawyer; or

b) discuss the material with another person, e.g. a parent, employer or health provider; or

c) disclose the information in another way; or

3. disclosure is otherwise required by law.

Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.

Fees

The fee of a consultation is payable either prior to the consultation by credit card or bank transfer. If payment is to be covered by a third party these details must be provided as soon as possible, along with acknowledgment by that third party that they will pay the cost of consultation sessions. Neurokids & Beyond's Fees schedule is attached.

Cancellation Policy

If, for some reason you need to cancel or postpone your appointment, please email reception@neurokidsandbeyond.com.au at least 48 hours notice, otherwise you will be charged 50% of the cost for the session.

My medical and contact details to be shared with other appropriate medical services at the discretion of the psychologist with my consent.

*

In the event of an emergency, NeuroKids & Beyond to access appropriate medical care for myself, at my expense.

*

I have read and understood this Consent Form. I agree to the above conditions for the service provided by NeuroKids & Beyond and acknowledge that I have read all relevant information about our service as available on our website or on request.

*

I give consent for the NeuroKids & Beyond Practitioner/Clinician to discuss myself/child with other NeuroKids & Beyond Practitioners/Clinicians at Peer Supervision, Meetings & Clinical Discussions.

Signature:

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