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

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

St Leonards NSW
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.

CHILD PSYCHIATRISTS: DR ROSEMARY ANDERSON AND DR KYLIE GULLIFORD BOOKS ARE OPEN.

ADULT PSYCHIATRISTS: DR MARYAM AGHDAEE AND DR NARGESS MAZLOUMI BOOKS ARE OPEN.

CLINICAL PSYCHOLOGISTS: DR JANE DE MATTEIS AND JACINTA GRIMA ARE ALSO ACCEPTING NEW PATIENTS. PLEASE NOTE CLINICAL PSYCHOLOGISTS ARE NOT ABLE TO PRESCRIBE MEDICATIONS.

* Once we receive the form it will take up to 7 days to call you back. If you are not available, we will leave a message. If we then haven’t heard back from you within 7 days we will assume you no longer wish to proceed and will destroy the form.

    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 Child Psychiatrists do you wish to see?
    Which Psychiatrist do you wish to see?
    Which Psychologist 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 of any previous professional involvements.

    List previous mental health admissions and dates. If applicable.

    TO BECOME A NEW PATIENTCLICK HERE
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