Family/Couple Intake Form

Family Name *

Primary Contact *

First

Last

DOB *

Gender

What are your correct pronouns?

e.g. he/him, she/her, they/them

Preferred Contact Number *

Email *

Referring GP

Address

Address Line 1

City

State / Province / Region

Postal Code

Family Details

Please list all Family Members Names, DOB & Gender

e.g John Smith, 01/01/2000, Male

Reason For Counselling

This information will help us find the best Psychologist for You

Please Specify

Are you experiencing any thoughts of self harm/suicidality currently?

Yes
No

Because you ticked yes to “self-harm suicidal thoughts” we have some further questions for you.

Do you have:

History of self harm?
History of previous suicide attempt?
Support currently?

Keeping Our Nala Community Safe

We take self-harm and suicidality seriously and we encourage you to access these services if you have an emergency as we are not an acute service.

In an emergency call 000 or visit your local emergency department.

There are many resources out there for immediate help for mental health concerns.

Mental Health Hotline - 1800 011 511

This line is staffed 24 hours a day, 7 days a week. You will be able to speak with a clinician who can provide recommendations about how to manage the situation or put you in contact with the appropriate mental health team.

Child & Youth Mental Health Service (CYMHS) – Northern Beaches - 9462 9222

This service consists of a team of mental health clinicians who provide specialist mental health intervention to children and young people with severe and complex mental health problems and their families.

Lifeline - 13 11 14 / 0477 13 11 14 (text service)

Suicide Call Back Service - 1300 659 467

A free service for people who are suicidal, caring for someone who is suicidal, bereaved by suicide or are health professionals supporting people affected by suicide. There is the option of online chatting, video call or phone counselling.

Kids Help Line - 1800 55 1800

beyondblue - 1300 224 636

1800Respect - 1800 737 732 – Sexual assault, family and domestic violence Line

Open Arms – Veterans & Families Counselling - 1800 011 046

Preferred therapy modality

Additional information

Current Home Situation *

Please include as much detail as possible.

Have the clients seen a psychologist previously?

Yes
No

How did you hear about us? *

General Information

Best day(s) for Nala to contact you?

Best time for Nala to contact you?

Morning
Afternoon

Please indicate if you are happy to have;

Morning Appointment
Telehealth Appointment

If you nominate availability for a morning and/or Telehealth appointment you are more likely to secure an appointment sooner.

Policies

Cancellation - We ask that clients contact the clinic no later than 11am of the previous business day if you are unable to attend, please cancel at your earliest opportunity via phone, text or email so that the appointment can be made available to others. In the event you don’t, a 100% cancellation fee will be incurred. This policy is explained during intake and at the initial appointment with your psychologist.