New Client Booking Form Welcome to Growth Psychology Practice.Please submit the below details to ensure we can match you with an appropriate Psychologist. "*" indicates required fields Step 1 of 3 33% Are you?* New client Returning client Who was your previous Psychologist? Your Name* First Last Email* Phone*Is this appointment for yourself?* Yes No (If No, please fill in the participants details) D.O.B DD slash MM slash YYYY Name of the participant to receive the service What is their relationship to you D.O.B of the participant DD slash MM slash YYYY Please select availability from the following: Any day or time Any day or time Or Choose from the following days and times. (AM: 9am-12pm) (PM: 1pm-5pm) Monday AM PM Tuesday AM PM Wednesday AM PM Thursday AM PM Friday AM PM Do you have a particular gender preference for a psychologist?* No preference Female Male Do you have a particular treatment approach preference?* No Yes (If yes, please list: for example: i.e. Cognitive Therapy, Exposure Therapy, Schema Therapy, EMDR, ACT, Hypnosis etc) Treatment approach preferenceCan you please describe what you will be seeking help for in a few short sentences?*Will you be utilising any of the following to assist you with the cost of therapy?* Medicare Private Health WorkSafe EAP NDIS TAC Other Do you have any previous or current diagnosis?* Are there any current or pending court orders in place?* Growth Psychology Practice is a private billing practice. Medicare and private health claims are supported, however unfortunately we are not able to offer Bulk Billing. We are not an NDIS-registered clinic therefore NDIS funding is accepted on a case-by-case basis for individuals who are either self-managed or have a plan manager. Reports PLEASE NOTE: Our experienced psychologists’ prime focus is to provide ongoing therapy to individuals and couples. We do not accept clients for the sole purpose of preparing reports or assessments for legal, education or other purposes. If you feel at any point that your mental health has deteriorated to the point where you can no longer cope and/or you are at risk of self-harm please go to your local hospital, call Lifeline 131 114 or Barwon Health Triage on 1300 094 187. We look forward to being able to assist you. If you have any further questions and would like to speak directly to one of our admin team, please do not hesitate to call our office at any time 03 5242 8637. The Team at Growth Psychology Practice. I have read and understand the above* I have read and understand the above Date* DD slash MM slash YYYY CAPTCHA
