Client Enquiry Form | Copeaheadpsychology

Full Name:

Birthday

Day

Month

Year

Address

Phone:

Email:

How did you find out about Cope Ahead Psychology?

What are some of the issues that brought you to Cope Ahead Psychology? If you have been referred and approved by Victim's Services for counselling, please provide your Victim's Services reference number below.

Please provide the details for an Emergency Contact Person

Have you presented to or been admitted to any Emergency Department or Psychiatric Unit in the last 6 months? If yes, please provide details.

Are you receiving any Specialised Care or Treatment at the moment? If yes, please provide the details of your Specialist or Treating Team. Eg. OBGYN, Psychiatrist, Paediatrician, OT, Antenatal Care Team or Mental Health Team.

Do you have private health care? If so, who is your provider?

Do you have funding for psychological services under the NDIS? If so, please note whether you are self managed or plan managed.

Are you involved in any current legal proceedings? If so, please provide further details.

Are you experiencing any current thoughts or intentions to self harm?

Do you have a Mental Health Care Plan provided by your GP? If so, please attach a copy below, or email a copy directly to admin@copeaheadpsychology.com.au

Upload - GP Mental Health Care Plan

If you have any other enquiries or feedback for Cope Ahead Psychology, please provide your details below and click 'Submit'

Client Enquiry Form Please complete the Enquiry Form below to help us determine the most appropriate and best way to help you at the moment. All information you provide is private and confidential.

Client Enquiry Form

Please complete the Enquiry Form below to help us determine the most appropriate and best way to help you at the moment. All information you provide is private and confidential.