New Clients - Psychology on Kew

If you would like to request an appointment please complete and submit the form below. We will respond within one business day.

Prior to submitting your intake request, please ensure that you familiarise yourself with our information and forms.

PLEASE NOTE: this is not a bulk billing service. All sessions must be paid for in full on the day of consultation. For information on medicare and private health insurance rebates click here.

Please complete and submit ALL REQUIRED FIELDS in the form below. Note that there is a Save and Continue Later button at the bottom of this form.

NEW CLIENT APPOINTMENT REQUEST FORM

First name*
Last name*
Address
Street Address * Address Line 2 City * State * Post Code * Country *
Email address*
Age*
Mobile phone number*
Date of birth*
MM slash DD slash YYYY
Briefly describe why you are coming, and what you would like assistance with (including any formal diagnoses if known)*
Do you have a current Mental Health Care Plan or an Eating Disorders Plan?*
Please note - you will not be eligible for medicare rebates UNLESS you have a Mental Health Care Plan or Eating Disorders Plan
If you are coming under a medicare-based plan, who is the referring medical practitioner, and what is the name of the referring Medical Practice?
Are there any constraints (financial or otherwise), on the number of sessions you can attend?*
Weekly appointments are recommended in the early stages of the treatment process. The frequency of appointments recommended after this time will depend on the nature of the presenting difficulties.
Preferred day(s) and time(s) for appointments
Please note that after-school times are limited due to high demand. If you are only able to attend appointments outside of the hours of 8am to 4pm you may be required to wait longer depending on our current capacities.
What kind of psychological service are you seeking?*
Are you able to attend appointments between the hours of 8am and 4pm?*
Please note we are only able to accommodate a certain number of clients at times after 4pm.
Is there any other information that it is important that we know?
Name of Emergency Contact Person*
(NB: This person would ONLY be contacted in the unlikely event of an acute emergency)
Mobile phone number of Emergency Contact*
Nature of relationship with the Emergency Contact*
Do you have any quick questions that you would like answered before your 1st appointment?
How did you hear about this practice?*
i.e., GP, internet search, APS Find a Psychologist, Healthshare, word of mouth, another psychologist, dietitian, psychiatrist, website etc
I am aware that this practice does not bulk bill, and that medicare rebates only cover a portion of the total fee(s).*
- Yes
I have double checked that I have completed ALL FIELDS marked with a * in the above form.*
PLEASE NOTE: we will not receive your form unless you complete ALL required fields marked with a *. You will know your form has been received if you are directed to a THANK YOU page immediately after submitting the form. If you do not hear from us after two business days, please email helena@psychologyonkew.com.au to check that we have received your form.
- Yes