Intake Questionnaire

intake form - new clients

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.

Title

Full Name

Preferred Name

Date of Birth

Address

Mobile

Occupation

How did you hear about us?

GP name

GP contact number

Medicare number

Medicare expiry date

Medicare position on the card

Emergency contact

Emergency contact number

Relationship to you

Marital Status

Names and ages of children (if any)

Have you previously received any mental health services (e.g., a counsellor or psychologist?)

Yes

If yes, please describe how long you saw the therapist for and for what reason

Have you ever been hospitalised for mental health concerns?

Are you currently taking any prescription medication for anxiety or depression?

Yes

If yes, please specify medication and purpose

How would you describe your current physical health?

How would you describe your current sleep?

Health concerns

Please describe your exercise habits

Eating patterns and appetite

Drug and/or alcohol use

Please describe the main reason you’ve reached out for support at BMAC

Please describe your goals in seeking mental health support

Anything else you'd like to add?

intake form - new clients

Thank you!

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intake form - new clients

Thank you!

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