Intake Form - Psych Clinic

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					                                                       PSYCHOLOGY CLINIC
                                                          INTAKE FORM
       Health Care / Pension Card #                                    Uni Student ID#                                  Fee: $15p/h / $30p/h
                                                                                                                     Assessment: $250 / $450
                                                                                                             Brochure: Y / N - Car Park     Y/N
                                                                                     Questionnaires for pre therapy (if applicable) given   Y/N
                                                                                                          Client Information form given     Y/N
                                                                                                                    Consent form given      Y/N
       If not a self-referral or child, is the client aware that a referral is being made?                YES / NO
       Is the referring agent/client aware that there is a fee for services in the Clinic?                YES / NO
       Is the referring person/client aware that assessments and treatments are undertaken by
       trainees who are completing specialist post-graduate training under supervision?                   YES / NO
       Advised client no rebates available from Medicare and private health providers.                    YES / NO
       Advised client that we cannot prepare Court reports or WorkCover claims                            YES / NO


       Date                                                                                    Intake Person

                                                                CLIENT DETAILS

       Mr, Mrs, Ms, Miss
                                              (first name)                              (last name)
       Parent
       (if applicable)                                                                                       Mother / Father / Carer

       Address

                                                                                                           Post Code       ________

       Date of birth       __________________            Age ________                                           Sex Male / Female

       Telephone                                         (home/work)         (mobile)                                      OK to text Y / N
                                                                                         Mobile connected to internet Y / N
       Email:

       Referrer or
       how did you                              (name)                                                (agency/organisation)
       hear about us?

                                               (position)                                               (phone number)

       GP name
                                                                                                        (phone number)
Problem reported by client/referrer




Current medication
Other information
What day/s suit client? (Circle)         Monday       Wednesday         Friday    Any day

Email: psychologyclinic@unisa.edu.au            Fax: 08 8302 4894: Please address to Psychology Clinic – UniSA – Magill Campus

				
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posted:12/25/2012
language:English
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