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.

Current Symptoms

Overview: Your responses will help the clinician understand how you're feeling and what symptoms you're currently experiencing.

Mental Health History

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

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.

Patient Details