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.

Are you experiencing any Covid symptoms?
Have you recently travelled overseas or interstate?
Are you or any family members subject to a Covid health directive?
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
I agree to wear a mask if mandated
I am fully vaccindated against Covid-19

Thanks for submitting this information!