Book An Appointment

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Child

Name of Child / Young Person

Gender

Date of Birth

Guardian 1

Name of Parent / Guardian 1

Mobile Number

Email Address

Guardian 2

Name of Parent / Guardian 2

Mobile Number

Email Address

Additional Information

Preferred Contact Person

Do you have sole parental responsibility for your child in the area of medical?

Name of referrer (if applicable)

Do both parents reside in the home?

Is there contact with the non-referring parent?

Please provide details.

What are the care arrangements (e.g., how many nights does the child/young person spend with each parent)? Please explain:

Is the non-referring parent aware of this referral?

Note: If you share responsibility of care with the non-referring parent (i.e., you do not have sole parental responsibility in the area of medical) - we require consent from both parents.

Are there any court orders (ivos, family court orders, custody arrangements) in place?

If yes, please explain

Do you intend your child to attend the clinic under any of the following funding options:

Who is the referring doctor/paediatrician?

Has the child accessed any sessions under a mental health care plan in this calendar year?

Please indicate if self-managed / plan-managed

Please specify….

Could you indicate the main concerns or challenges you are seeking support with?

Are there any high-risk behaviours that you are particularly concerned about?

Availability preferences (are there any days you are not available)?

Please indicate which clinic you would like to attend:

Please note for our Ivanhoe clinic – we are only accessible by stairs. Is this suitable for you?

Please note we are not a crisis service. For immediate support, please call 000, or contact your local emergency department.

I understand that this is not an emergency/crisis service