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ICP New Client Intake Form

Please complete and submit this form prior to attending your appointment. All information will be stored confidentially and only shared with your Psychologist.

Important: This form must be completed and reviewed before an appointment is considered confirmed.  It is the discretion of the treating Psychologist to confirm this appointment and also determine whether the treatment is completed in person or remotely.

Please note: Medicare rebates only apply to individuals with a current and valid Mental Health Care Plan. ICP can only lodge your Medicare rebate claim; and does not control the Medicare rebate payment process into your bank account.  If preferred, you can claim the Medicare rebate yourself after your appointment, by submitting your paid receipt directly to Medicare for review.

Are you experiencing any Covid or flu symptoms?
Are you comfortable completing your appointment via Telehealth if required?
Are there any health conditions we should be aware of?
Are you on any medications

Thanks for submitting this information.

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