Patients Assessment Form - ProMind Psychology

Are you booking for yourself or someone else?

Self Someone else

Are they currently experiencing any thoughts or suicide or self-harm?

Yes No

Mental health is important to us. However, please note that our service is not designed to handle immediate crisis situations. If someone you know is experiencing a mental health emergency or are at risk of harm to themselves or others, please contact emergency services immediately.

Emergency: 000

Lifeline: 13 12 14

Suicide Call Back Service: 100 659 467

Beyond Blue: 1300 22 4636

Are you currently experiencing any thoughts or suicide or self-harm?

Yes No

Mental health is important to us. However, please note that our service is not designed to handle immediate crisis situations. If someone you know is experiencing a mental health emergency or are at risk of harm to themselves or others, please contact emergency services immediately.

Emergency: 000

Lifeline: 13 12 14

Suicide Call Back Service: 100 659 467

Beyond Blue: 1300 22 4636

Are you booking on behalf of a minor?

Yes No

Are there any family separation or court matters in place?

Yes No

: Please note - we do not provide services for family court matters or provide court reports and will require consent from both parents for therapy. We also recommend that the initial appointment is a parent-only appointment, so that your clinician will have the chance to talk openly about your concerns.

Proceed

ِWhat is the age of the individual seeking therapy?

ِ10 - 18yo 19 - 25yo 26 - 35yo 36 - 45yo 46 - 55yo 56 - 65yo 66 Up

ِDo you or the person you are making the booking for have (or are about to get) a mental health care plan referral from a GP?

Yes No

Please note that we are not a bulk billing clinic, and as a result, there will be out-of-pocket costs associated with our services. The cost will depend on which psychologist you book with.

Proceed

ِAre you or the other person being covered by any other agency? If yes, please select the relevant agency below.

Private Health CTP/MVA RTW NDIS (self-managed) NDIS (plan managed) Dept of Veteran Affairs Self-funded Other

Please note – to confirm your appointment, we require a deposit.

Proceed

ِDo you or the person you’re booking for prefer primarily Telehealth, face to face appointments, or are you open to both?

Face to Face Telehealth I don’t mind

ِDo you require any specific times or days for your appointments?

Yes No

ِPlease indicate what days/times that are required. Please select as many as possible.

Proceed

ِPlease select up to two reasons for accessing therapy services:

Maximum 2 Selections

Please give our clinic a call on 08 8166 7566 to discuss any queries with one of our friendly admin staff.

ِChoosing the right psychologist involves finding a compatible personality match. Please specify up to 3 therapy styles that align best with your preferences:

Maximum 3 Selections

Like a coach Has a sense of humour Is good at “tough love” Is creative Is sensitive and gentle Will hold you to your commitments Will hold space for you and let you talk Will give you lots of skills and solutions to work through life Something else

Please Wait..

Thanks for booking online. See below some of our psychologists we think would be a ‘perfect match’.