Patient Intake Form

    Child Psychiatry • Adult Psychiatry • Paediatrics

    Important: Submitting a request does not guarantee acceptance. Review takes up to 4 business days. We do not provide emergency/crisis care.

    Appointment Type*


    Patient Details


    Parent / Guardian Details (if applicable)


    Reason for Appointment

    Acute risk of suicide/harm?


    Neurodevelopmental Disorders (Tick all that apply)




    Do you have a GP referral?



    Family / Custody / Legal Information

    Parents:

    Ongoing court proceedings?

    AVOs or Child Protection Concerns?


    Immediate safety concerns?



    Consent