Intake Parent Questionnaire

intake form - parent questionnaire

Thanks for taking the time to complete this form prior to your appointment at Blue Mountains Anxiety Clinic.
Please note: information provided on this form is confidential, but if there is anything here that you would 
rather talk about with Gina in person, then please just leave that bit blank.

Your child's name

Young person's preferred name

Date of birth

How did you hear about us?

School and current grade

Address

Parent/Guardian #1 full name

Parent/Guardian #1 address

Parent/Guardian #1's mobile

Parent/Guardian #2's full name

Parent/Guardian #2's address

Parent/Guardian #2's mobile

Names and ages of any siblings

Do you have a referral and Mental Health Treatment Plan? Please note referrals are not necessary unless you wish to claim Medicare rebates on fees.

YesNo

Referrer details

Medical information

Paediatrician details

Has your child ever been diagnosed or treated for a mental health condition?

YesNo

If yes, please provide details

Medical history

Developmental history

Eating patterns and appetite

Does your child have any sleep problems?

What are your main concerns for your child?

Please describe your goals in seeking mental health support for your child

intake form - parent questionnaire

Thank you!

Error