Mental Health Consultations

Reason for Consultation

Important: This form is designed to help your clinician understand your mental health concerns ahead of your consultation. Please answer honestly. All responses are confidential and will be reviewed by a licensed healthcare professional.

Note: This form is not monitored in real-time. If you are in crisis or at risk of harm, please call 000 or attend the nearest emergency department.

What is the main reason you are seeking mental health support? *

Have you experienced this issue before? *

Yes No

Have you received mental health support in the past?

Yes No

If yes, please briefly describe the type of support you received:

Mental Health History

Context: Please provide any relevant background so the clinician can offer informed and appropriate support.

Do you have a history of diagnosed mental health conditions?

Yes No Unsure

Have you ever taken medication for a mental health condition?

Yes No

If yes, which medications have you taken or are currently taking?

Do you currently have a mental health care plan from a GP?

Yes No

Consent & Signature

Consent: I confirm that the information I have provided is true to the best of my knowledge. I understand that this is an initial mental health consultation and that further follow-up or referral may be recommended based on clinical judgement.

Acknowledgement *

I confirm the information provided is accurate and I understand that this is not a crisis service.

Signature *

Patient Details

First Name *

Last Name *

Email *

Phone Number *

Medicare Number *

Medicare Reference *

Address Line 1 *

Address Line 2

City *

State *

Post Code *

Country *

Date of Birth *

Mental Health Consultations

Book a Mental Health Consultation

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Order Summary

Reason for Consultation

What is the main reason you are seeking mental health support? *

Have you experienced this issue before? *

Have you received mental health support in the past?

If yes, please briefly describe the type of support you received:

Current Symptoms

Which of the following are you currently experiencing? (Tick all that apply) *

When did these symptoms begin? *

Are these symptoms affecting your daily life? *

Mental Health History

Do you have a history of diagnosed mental health conditions?

Have you ever taken medication for a mental health condition?

If yes, which medications have you taken or are currently taking?

Do you currently have a mental health care plan from a GP?

Consent & Signature

Acknowledgement *

Signature *

Patient Details