Website Inquiry Questionnaire

First Name *

Last Name *

Email Address *

Date of Birth *

Contact Number *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Country

What are your main concerns? *

Current Diagnoses: *

Have you seen a psychologist before? *

YesNo

If yes, collectively how long have you been seeing your psychologist/psychiatrist?

What type of support are you seeking? *

EMDRShirt term support (e.g. up to 6 sessions)Assessment or second opinionTherapy for a child or adolescent CBT, ACT, MCTParent or family interventionsUnsure - I'd like to talk it through

Are you currently taking any medications? If so, please list below

Have you had previous admissions to a psychiatric hospital? *

YesNo

Have you ever experienced the following: *

Alcohol abuseDrug abuseExtreme depression Wild mood swingsRapid speechExtreme anxietyPanic attacksDifficulty breathingPhobiasSleep disturbancesTraumatic experiencesHallucinationsDisordered eatingBody image problemsRepetitive thoughts (obsessions)Repetitive behaviours (checking, hand washing)HoardingHomicidal thoughtsSuicidal thoughtsSelf harmSuicide attemptNone of the above

Do you have any mobility limitations?

YesNo

What personality traits would you like in a therapist?

IntrovertExtrovertI don't mind

What bst days and times suit you for appointments?

Weekday morningsWeekday afternoonsWeekday after 5:00pm (higher fee applies)Saturday (higher fee applies)Flexible

Who among the team would you prefer to see?

I don't mindEmily O'LearyKim StirlingZoe QuickNidhi GuptaTaylor Jane CoxFreya YoungDaphne BryanIsaac DeveryShireen AliIan McKerrellNatasha RoughanSally YoudaleAbby KortlangSidonie SkibaChelsea NicolGeorgia CoonanConnor DoigJoshua JentjensOlivia BateupClaudia Kinnane Sara Jacobsen

How did you hear about us?

Yes, I acknowledge that the OCD Clinic does not bill directly to DVA, Workcover or Third Party Insurances. *

Yes, I acknowledge that the OCD Clinic does not invoice using NDIS line item codes. If you are an NDIS participant, you will need to pay for services privately or use a Mental Health Care Plan which can be obtained through your treating General Practitioner. *

Verify *

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