Maryborough Psychology & Health Clinic

Melinda Metaxas & Associates Pty Ltd

Child & Adolescent Intake Form

We would appreciate if you could please answer the following questions so that we can understand your child's circumstances better. This will help us to link your child to the appropriate clinician and service so that they can receive the most relevant intervention and assistance. The more information you provide, the greater our ability to support you. All of the information that you provide remains confidential and protected

You are the child's...
Does your child have a Mental Health Care Plan/Medicare GP referral?
Does your child have an NDIS Plan?
My child wishes to access this service using:
Does your child have a diagnosed disability, medical condition or delayed development?
Does your child have behaviour problems
Has your child accessed any other service / intervention in the past? If so, what?
Have you attended our clinic before?
My child would like help for:
Are there any family court/custody matters or DHHS orders/involvement?
Are there possible or known issues of sexual abuse?
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Thank you! Your information was sent successfully. We will be in touch as soon as an appointment becomes available!