Complete A Care Assessment

Bacchus Marsh
Ballarat
Cranbourne
Geelong
Melton

Answered 0/19 questions

Welcome! We are very glad you’ve found us. Below is an intake form we need you to complete in full so we have all necessary details to make your first session as smooth as possible. With regards to the funding of your sessions, if you have a Mental Health Care Plan, it must be sent through in full or uploaded here to be eligible for a Medicare Rebate. If you are funded by a third party (i.e. NDIS Plan Manager, Worksafe, TAC etc) we require written confirmation that psychology is an approved service. Please upload this at the end of the form or send it through to us via email. Please note, we have locations in Ballarat, Geelong, Bacchus Marsh, Melton, and Cranbourne. We also practice from many schools and via Telehealth.

1.First Name

2.Last Name

3.Preferred Name

Please add the name and date of birth of the person requiring the service. If the person is a minor, there will be an option to add parent/guardian details further in the form.

4.Name of person requiring service

5.Date of Birth

6.Email Address

7.Phone Number

8.Residential Address

9.Preferred location

10.Gender identity

11.How will sessions be funded?

12.If Medicare / NDIS / Worksafe / TAC — please share the referring GP, plan manager, or case manager details.

13.What brings you to ANSA Health today? Please share the main concerns you would like support with.

14.Have you previously accessed psychology, counselling or mental health support? If yes, please share what was helpful.

15.Are you currently taking any medications relevant to your mental or physical health?

16.Emergency contact — full name

17.Emergency contact — phone

18.How did you hear about ANSA Health?

19.Any additional context you would like your clinician to know before the first session?