Confidential Information

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Date

Name

First

Last

Address: Number and Street

Suburb

Postcode

Phone number: work / home / mobile

Age

Date of birth

Highest education

Occupation

Person to contact in the event of medical emergency

Relationship to you

Phone

GP name

No. of GP

GP Address

Referred by

Medicare number

Medicare reference number

Relationship status

Spouse/partner's name

Children (gender, ages)

Please describe any significant current or past medical or mental health problems

Please list any medications you currently take for mental health issues only. Include prescription and over-the counter medications and the dosage of each

Have you had previous counselling or psychiatric care?

If yes, when?

Have you ever been hospitalised for a psychological difficulty

If yes, when?

If you are on a Mental Health Care Plan, have you had any previous sessions on this Plan?

If yes, when?