Mental Health Support: For the Post Pandemic Period Intake Form

Once you have completed this form an administration officer will contact the client within 3 working days to organise services.

Psychcentral

ABN: 12101 099 521

Contact us : 1300 856 779

Email us: mentalhealth@psychcentral.com.au

General Information

Patient First Name *

Patient Surname *

Date of Birth *

Email Address *

Contact Number *

Medicare Card Number *

Medicare Card Reference *

Home Address *

CALD Background (Languages other than English spoken, cultural background) *

Does patient identify as Aboriginal or Torres Strait Islander (If no leave blank) *

Emergency Contact Information

Emergency Contact Name *

Phone *

Emergency contact’s relationship to the client *

Post Pandemic Symptoms List

Have you expereinced any of the following symptoms within the past 12 months (post pandemic period) *

Feelings of isolation/disconnection Sustained low mood Feeling anxious and fearful Shortness of breath Ongoing fatigue Problems with memory and concentration (brain fog)Problem in Sleeping Changes in Mood Ongoing lethargy and inability to 'bounce back' after the prolonged pandemic period Grief and loss due to loss of a loved one during the pandemic period

What main supports are required from the Post Pandemic Support Program? (pick all that apply) *

PsychologyExercise Physiology Dietetics

Referring GP or Healthcare Provider Name *

Referring GP or Healthcare Provider Number *

GP /Healthcare Provider Contact Details *

GP/ Healthcare Provider Address *

Date of Referral *

Consent

I confirm that above information I have provided is true, complete and accurate. *

Signature *

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Date *

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