Classic form

Psychology intake form with the limits of confidentiality on it

A first psychology session has fifty minutes and a person who has usually waited weeks for it, so the history should not eat the first twenty. This twenty field intake form takes the referral pathway, a ten item distress baseline and the supports already in place, and states the limits of confidentiality above the signature.

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New client form, Lakeside Psychology

Please complete before your first session. Nothing here is a test and there are no wrong answers. If a question is hard to answer, leave the written ones short and bring them to the session instead.

About you

Your name *

First

Last

Preferred name and pronouns

Date of birth *

Mobile *

Email *

Address, including suburb, state and postcode *

Is it alright to leave a message? *

Yes, a voicemail and a text are both fine

Text only, no voicemail

Voicemail only

Neither, please just try again

Email only

How you are coming to see us

Referral pathway *

GP mental health treatment plan

Referral from a psychiatrist

Self referred, paying privately

NDIS, self managed or plan managed

Workers compensation

Employee assistance programme through my work

Not sure, please check for me

Referring doctor and clinic, if you have a referral

Sessions already used under a plan this calendar year

What you write from here is health information. It is read by your psychologist, held securely in the practice records, and is not shared with your referring doctor beyond a short letter about progress, or with anyone else, without your consent. The exceptions are set out in the consent section at the end and are explained in the first session.

What brings you here

What would you like help with? *

How long has this been going on? *

Weeks

A few months

6 to 12 months

1 to 3 years

Longer than 3 years

On and off for as long as I remember

The next question asks about the last four weeks. It is a ten item distress screen written in the practice own words, used to get a baseline rather than to give a diagnosis, and the same ten statements are repeated later so that change can be seen. Answer for how things have actually been rather than how you think they should have been.

In the last four weeks, how often have you felt this way? *

	None of the time	A little	Some of the time	Most of the time	All of the time
Worn out without a clear reason
On edge or keyed up
So on edge that nothing settled you
That things were not going to get better
Unable to sit still or settle
So unsettled that you had to keep moving
Flat or low in mood
That ordinary tasks took more out of you than they should
That nothing lifted your mood
That you were of little value

Which of these have been part of the last month? *

Sleep that is broken, too short or too long

Appetite or weight has changed noticeably

Drinking more, or using something more than usual

Withdrawing from people I would normally see

Trouble at work or with study

Conflict at home or in a relationship

Panic attacks

Grief or a recent loss

None of these

History and support

Have you seen a psychologist, counsellor or psychiatrist before? *

No, this is the first time

Yes, and it helped

Yes, and it was not the right fit

Yes, and I stopped going before I meant to

Yes, I am seeing someone else at the moment

List anything you take regularly, including medication prescribed for mental health, for anything physical, and supplements. Doses are useful where you know them. Leave the table blank if there is nothing.

Medications and supplements

#	Name	Dose	How long you have taken it	What it is for
1
2
3
4

What support do you already have? *

A GP I see regularly

Family I can talk to

Close friends

A partner

A support group or community

Faith or a spiritual community

A case manager or support coordinator

Not much at the moment

Emergency contact: name, relationship and phone *

Consent and the limits of confidentiality

What you discuss stays between you and your psychologist, with four exceptions that the law and professional practice require: where there is a serious and imminent risk to your life or to someone else, where a child is at risk of harm, where records are subpoenaed by a court, and where you give written consent for information to be released. Your psychologist will talk this through in the first session, including what would happen and who would be contacted. Fees are payable on the day. If you are ever in immediate danger, call 000, and Lifeline is available on 13 11 14 at any hour.

Consent *

I have read the limits of confidentiality above and I understand them

I consent to assessment and to psychological treatment

I agree to the fee and cancellation terms sent with my booking confirmation

Signature *

Every field, and what it collects

The complete field list, in the order respondents meet it.

Your nameNameRequired
Preferred name and pronounsShort text
Date of birthDateRequired
MobileShort textRequired
EmailShort textRequired
Address, including suburb, state and postcodeShort textRequired
Is it alright to leave a message?Single choiceRequired: Options: Yes, a voicemail and a text are both fine · Text only, no voicemail · Voicemail only · Neither, please just try again · Email only
Referral pathwaySingle choiceRequired: Options: GP mental health treatment plan · Referral from a psychiatrist · Self referred, paying privately · NDIS, self managed or plan managed · Workers compensation · Employee assistance programme through my work · Not sure, please check for me
Referring doctor and clinic, if you have a referralShort text
Sessions already used under a plan this calendar yearNumber
What would you like help with?Long textRequired
How long has this been going on?Single choiceRequired: Options: Weeks · A few months · 6 to 12 months · 1 to 3 years · Longer than 3 years · On and off for as long as I remember
In the last four weeks, how often have you felt this way?Rating gridRequired: Statements:
Worn out without a clear reason
On edge or keyed up
So on edge that nothing settled you
That things were not going to get better
Unable to sit still or settle
So unsettled that you had to keep moving
Flat or low in mood
That ordinary tasks took more out of you than they should
That nothing lifted your mood
That you were of little value
Which of these have been part of the last month?Multiple choiceRequired: Options: Sleep that is broken, too short or too long · Appetite or weight has changed noticeably · Drinking more, or using something more than usual · Withdrawing from people I would normally see · Trouble at work or with study · Conflict at home or in a relationship · Panic attacks · Grief or a recent loss · None of these
Have you seen a psychologist, counsellor or psychiatrist before?Single choiceRequired: Options: No, this is the first time · Yes, and it helped · Yes, and it was not the right fit · Yes, and I stopped going before I meant to · Yes, I am seeing someone else at the moment
Medications and supplementsTable: Columns: Name · Dose · How long you have taken it · What it is for
What support do you already have?Multiple choiceRequired: Options: A GP I see regularly · Family I can talk to · Close friends · A partner · A support group or community · Faith or a spiritual community · A case manager or support coordinator · Not much at the moment
Emergency contact: name, relationship and phoneShort textRequired
ConsentMultiple choiceRequired: Options: I have read the limits of confidentiality above and I understand them · I consent to assessment and to psychological treatment · I agree to the fee and cancellation terms sent with my booking confirmation
SignatureSignatureRequired

What each block of this form collects

The identity block includes a preferred name and pronouns field that is optional and used from the first session, and a question about leaving a message that offers text only and voicemail only as separate answers, because for a lot of clients that is the difference between a practice being safe to contact them and not. The referral block asks the pathway, the referring doctor and the number of plan sessions already used this year, which is the number that decides how many remain. The history block opens with a written question that the placeholder deliberately keeps low pressure, then the distress grid, then a tick list of what has been part of the last month. Support asks about previous therapy and about who is already around the person.

The Australian pieces on this form

The referral radio names the pathways an Australian practice actually bills against, starting with a GP mental health treatment plan, which carries a set number of rebated sessions in a calendar year, and including NDIS, workers compensation and an employee assistance programme. The sessions used number is asked because the count resets annually and clients routinely lose track of it, and getting it before the first appointment stops a rebate failing at the desk. No Medicare number is collected anywhere on the form; the card is sighted at reception. Psychologists are registered with the national board and bound by a professional code of conduct, and the two crisis numbers named in the consent paragraph and the thank you screen are the national ones.

How to adapt this form

A child and adolescent practice adds a parent or guardian block, a school and year field, and a question about who else is involved such as a paediatrician or a school wellbeing team, and splits the distress grid into a version the young person answers and a shorter one the parent answers. A couples practice removes the distress grid entirely, since it is an individual measure, and replaces it with a relationship history block and a question about whether both partners are attending. A practice doing a lot of workers compensation adds an employer, insurer and claim number block and a separate consent tick for reporting to the insurer, which should never be folded into general consent.

What makes this form work

Ten statements, one five point scale

Worn out without a clear reason through to feeling of little value, each rated none of the time to all of the time over the last four weeks. One grid gives the psychologist a baseline in two minutes, and the paragraph above it says plainly that it is a screen and not a diagnosis.

Four named limits, not a general clause

Serious and imminent risk, a child at risk of harm, a subpoena, and written consent to release. Naming them individually above the consent ticks is what makes the first tick meaningful, and the paragraph promises the same conversation again in the first session.

Plan sessions used is a number field

One field, capped between zero and forty, asked beside the referring doctor. It is the figure that decides how many rebated sessions remain in the calendar year, and getting it here stops a rebate failing at reception after a first appointment.

Questions people ask

Why does an intake form ask whether it is alright to leave a message?

Because a voicemail can be heard by someone else in the house, and for a client managing a difficult relationship that is a real risk. Offering text only and voicemail only as separate options, plus neither, lets the practice make contact in a way that is safe. It takes one question and it is asked before anything sensitive.

What is the ten item screen actually measuring?

General psychological distress over the last four weeks, rated on a five point frequency scale from none of the time to all of the time. The paragraph above calls it a baseline rather than a diagnosis and says the statements are the practice own wording, which is the honest description of what a screening measure does.

Why ask how many plan sessions have been used this year?

Because rebated sessions under a mental health treatment plan are counted per calendar year and clients rarely track them. Asking before the first appointment means the practice can tell somebody they have two sessions left rather than discovering it when a claim is rejected at the desk, which is a bad way to end a first session.

Should the limits of confidentiality be on the form or left to the session?

Both, and this form says so. The paragraph names four specific exceptions, serious and imminent risk, a child at risk of harm, a subpoena and written consent to release, and then says the psychologist will talk it through in the first session including who would be contacted. Reading it beforehand means the conversation starts from understanding.

Why is the medications table optional?

Because a required table forces somebody who takes nothing to type none into four rows, and because a client who cannot remember a dose should not be blocked from submitting. The paragraph above says to leave it blank if there is nothing.

What if somebody cannot finish the form?

The welcome screen says to send it half finished and say so, and the introduction says to keep the written answers short and bring them to the session instead. An intake form that a distressed person cannot complete simply does not get sent, and a first appointment with a partly filled form is far better than a cancelled one.

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Sources

Written and checked by the OneCraft team. Last checked 12 September 2026.