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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.

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Marital Status
Have you previously received any mental health services (e.g., a counsellor or psychologist?)
Are you currently taking any prescription medication for anxiety or depression?
How would you describe your current physical health?
Blue Mountains Anxiety Clinic sits within the lands of the Darug and Gundungurra peoples. We acknowledge the Traditional Owners of country throughout Australia and recognise their continuing connection to land, waters and culture. We pay our respects to their Elders past, present and emerging and recognise their strength, capacity, diversity and resilience.
02 4702 0261          
Blue Mountains Anxiety Clinic | Suite 6 The Spires | 118 - 124 Leura Mall | Leura NSW 2780 | Australia
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