Tel: 0299065319 | Mon-Frid 9am-5pm

reception@familytalksclinic.com.au
Level 4 & 3, 30 Atchison Street

St Leonards NSW 2065
If risk is immediate

Call Lifeline on 131114

 NEW PATIENT FORM

Request an appointment

 

Complete the new patient request form online.

This form allows us to review your situation to ensure we best serve your needs.

We offer professional services ranging from psychologists, child and adolescent psychiatrists, adult psychiatrists, and family therapists, working independently and together to offer the best in field holistic approach.

If you are not able to select your chosen clinician on the form below, this means that they are not accepting new patients. We do not keep a waitlist. Your options are to choose another clinician or ask your GP to recommend another clinic. Please be aware that psychologists are not able to prescribe medications.

We will respond to your request within 7-9 working days.

    Name

    Patient/Client Date of birth (day/month/year)

    Name of school/University/Occupation

    Sex assigned at Birth

    If under 18 years: Consent given by: Name of parent (s): Guardian (s)

    Name of key contact if different to patient/client

    Telephone/mobile

    Email

    Which Clinician do you wish to see?

    Which Adolescent and Adult Psychiatrists do you wish to see?

    Which Psychologist do you wish to see?

    Which Family Therapists do you wish to see?

    Has the patient/client been diagnosed with any developmental disorders?

    Does the patient/client display disruptive behaviours?

    Please provide a short summary of the situation / background and what has happened to cause you to seek help now?

    What do you hope to be able to do or achieve as a result of treatment?

    Is there an acute risk of suicide or harm to others?

    Name(s) of any previous mental health professional or organisational involvement.

    List previous mental health admissions and dates. If applicable.

    TO BECOME A NEW PATIENTCLICK HERE
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