Book Now: Individual New Client Form

To make an appointment complete the enquiry form below and our friendly support team will be in contact.

If you have any trouble using this form don’t hesitate to call us on (03) 9376 1958 or email us here.

    * required

    Please tick below to show that you understand the following:

    These questions help us to match you up to the right team member. Some are optional, and some are required to make a booking.

    Your first name*

    Your surname*

    Your mobile number*

    Your email*

    How would you like to be contacted?*
    Unfortunately if you don't feel comfortable for us to contact you via either phone or email we are not able to assist you. If the reason you don't feel comfortable with us contacting you via either of these methods is due to family violence, we'd recommend you contact 1800 RESPECT on 1800 737 732 for further assistance.
    Phone callEmailEither, I don't mind

    Your current address*
    If your current address is not the same as the address you have registered with Medicare, please update your address with Medicare before your first appointment.

    Street address

    Suburb
    Postcode

    How did you hear about Inner Melbourne Clinical Psychology?*

    Date of birth (day/month/year)*

    Which location would you prefer? (You can choose more than one)*
    KensingtonMelbourne CBDFitzroy NorthTelehealthNo preference

    Which days/times would you prefer? (You can choose more than one option)*
    Monday 9-4pmMonday 4pm onwardsTuesday 9-4pmTuesday 4pm onwardsWednesday 9-4pmWednesday 4pm onwardsThursday 9-4pmThursday 4pm onwardsFriday 9-4pmFriday 4pm onwardsSaturday 9-3pmNo preference

    Is there a particular psychologist you would like to see?
    Our Support Team will endeavour to match you with your preferred psychologist if their availability allows

    All of our psychologists are LGBTQIA+ affirmative, but if you would like to work with someone who also has specific training and experience in working with these communities, please tick this box and we'll ensure you're matched with someone who is suitable.
    Yes, I would like to be matched with a psychologist trained and experienced with LGBTQIA+ communities.

     
    Please tick the issue/s you would like help with (please select at least one issue)*

    Of the issues above which one feels like the main issue, or the one you feel most concerned about?

    Who diagnosed you with bipolar (e.g. your GP, a psychiatrist, a psychologist or self-diagnosed) and when was the diagnosis made?*

    Can you provide us with any additional information about the bipolar symptoms you experience? For example, have you been diagnosed with bipolar type 1, bipolar type 2, cyclothymia or some other type of bipolar related condition? Have you experienced any manic or hypomanic episodes and if so, when was the most recent episode?*

    If you are currently seeing a psychiatrist, please provide their name and phone number.*

    Please list the name and dosage of any medication you are currently taking for your mental health.*

    When people mention drug and alcohol issues we ask a few extra questions. This information is really helpful in assisting us to figure out whether our clinic is the best place for you to get support.

    If you have trouble answering these further questions, please just write "I don't know" and we'll be in touch with you to try to figure it out together.

    Which substance(s) you are wanting assistance with?*

    How often are you currently using this substance(s) per week?*

    Are you currently seeing a GP or a psychiatrist for medical support? If so, please note their name and clinic name.*

    To book you in, we will need the following details about your partner:

    Please be aware that if you do book an appointment with us, we will contact both yourself and your partner with appointment details and information.

    Partner's full name*

    Partner's date of birth*

    Partner's phone number*

    Partner's email address*

    Partner's current address*

    Please tell us a little about what is bringing you and your partner in. For example, conflict resolution, infidelity, improving communication, parenting or navigating change.*

    When clients mention they are wanting help with an eating disorder we ask a few extra questions. This information is really helpful in assisting us to figure out whether our clinic is the best place for you to get support. If you have trouble answering these further questions, please just write "I don't know" and we'll be in touch with you to try to figure it out together.

    How long have you had eating disorder symptoms?*

    Have you received treatment in the past?*

    If yes, can you tell us who with - for example, a psychologist, psychiatrist or hospital-based treatment?

    Are you currently on any prescription medication?*

    Are eating disorder symptoms the main reason you are seeking therapy, or is there something else that feels more pressing or concerning?*

    Are you currently seeing any other health professionals such as a GP, dietician or other psychologist?*

    When clients mention anger management we like to ask a few extra questions to help us to figure out whether our clinic is the best place for you to get support.

    If you have trouble answering these further questions, please just write "I don't know" and we'll be in touch with you to try to figure it out together.

    Can you let us know more about the specific issues you are having with your anger?*

    Has your anger ever resulted in you being violent? Please provide more information if so.*

    Please provide some more information about your concerns around obsessions and compulsions. If you have trouble answering this question, please just write "I don't know" and we'll be in touch with you to try to figure it out together.

    Have you been diagnosed with psychosis by a GP, psychiatrist or other mental health professional?*
    YesNo

    If you have trouble answering these further questions, please just write "I don't know" and we'll be in touch with you to try to figure it out together.

    Please provide us with some information about who made this diagnosis and when this occurred?*

    If you are currently seeing a psychiatrist, please provide their name and phone number.*

    If you are currently taking medication, please let us know which type of medication and what dose you are taking.*

    What type of phobia do you have? For example, needle phobia, phobia of heights or phobia of small spaces.*

    Please let us know if there is any other information that you think it would be helpful for us to know when matching you up with one of our psychologists.

    Do you have a Medicare referral/GP letter/Mental Health Treatment Plan?
    YesNoUnsure

    If yes, what is the name of your GP and/or your GP clinic?

    What is the date of your referral or letter?

    If you have already used sessions with another psychologist, how many have you used since 1st January this year?
    If you are unsure about this you would need to speak with Medicare (Ph: 132 011) and bring this information along to your first session.

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