Client Intake and Consent

Who is the person receiving therapy or being assessed?

First Name *

Last Name *

Date of Birth *

Gender Assigned at Birth *

Current Gender Identity *

School Year *

Referring Doctor (if applicable)

What service are you requesting?

Psychological AssessmentPsychological Therapy

What assessments are you requesting? *

Cognitive AbilitiesAcademic SkillsSocial-Emotional-BehaviouralAutism Spectrum Disorder

How will you be paying the fee? (This helps me to invoice you correctly!) *

NDIS FundingMedicare - GP Mental Health Care Plan (for therapy only)Private HealthNone of the Above

NDIS Client Number *

Please Note: You are unable to use NDIS funds for our services if your plan is Agency Managed.

NDIS Plan Management *

Self ManagedPlan Managed

Name of Plan Management Organisation *

Name of Private Health Fund *

Please forward a copy of the GP Mental Health Care Plan to: brainstorm.referrals@gmail.com

Contact Details

What is your residential address? *

Street address *

City *

State *

Postcode *

Email Address *

Phone Number: *

Who is the person completing this form?

Your First Name: *

Your Last Name: *

I hereby acknowledge that I am authorised to provide consent for the person named above as the person receiving the psychological services. I hereby provide consent for the psychological assessment or psychological therapy to be administered. I have read the practice information regarding booking conditions and fees and I agree to these terms. *

Signature of Person Receiving Service (if applicable)

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SIgnature of Person Completing Form

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Tell Me You Are Human! *