Client Form - Inside Out Therapy

Child's name

Child's D.O.B

Person Making Referral Name

Relationship to the child? Mother, Father, Grandparent, Guardian.

Email Address

Phone Number

Address

Child's school, suburb and class

Diagnosis

Concerns (please give as much detail as possible to help us triage your referral)

Please outline funding here

To ensure everyone's safety please answer the following questions

Are there any court orders or parenting arrangements we need to aware of?

Does the client have any allergies, chronic illness or medical issues we need to be aware of?

Are there any concerns with having to wait in a busy waiting room?

Does the client have any sensitivities or dislikes we need to be aware of?

Does the client have difficulty finishing or leaving appointments?

Does the client ever abscond (run away) or wander?

Does the client present with unexpected aggressive or violent behaviours?

Allergy to dogs?

Fear of dogs?

Please tell us more about the options selected above

Preferred therapy days and times

Please note after school timeslots are highly sought after. We ask that you consider initially taking an alternative timeslot in the meantime.

Note: Psychology is currently only available at our Kallangur and Zillmere clinics.

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