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Home
About
Services
Individual Therapy
Prenatal and Postnatal Services
Couples Therapy
Group Therapy
Individual Supervision
Contact
Client Enquiry Form
Helpful Resources
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.
Full Name:
*
Date of Birth:
*
Day
Month
Month
Year
Phone:
*
Address:
*
Email:
*
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.
*
Please tick the type of sessions you are enquiring about
*
Face to Face sessions
Groups Sessions
Video Sessions
Couples Sessions
Telephone Sessions
Individual Supervision Sessions
Victim's Services Counselling
Corporate Psychoeducational Sessions
Who is your Emergency Contact? Please provide their name and a valid phone number.
*
Are you under the care of a Psychiatrist, OBGYN, Paediatrician? If yes, who do you see?
*
Do you have private health cover? If yes, which fund?
*
Are there any court or legal proceedings we need to be aware of? Do you have any criminal convictions? Do you require a report for any legal matters?
*
Have you had any presentations to the Emergency Department or admissions to any local hospitals in the last 6 months for mental health concerns?
*
Do you currently feel at risk of harming yourself or anyone else?
*
Do you have a GP Referral and/or Mental Health Care Plan?
*
Additional Enquiries for Cope Ahead Psychology:
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