Intake form - child

This form should be completed by parents or legal guardians of persons under 18 years of age.

After submitting this form, you may be contacted to confirm your child's suitability for Wise Psychology's services and establish a day and time for their first appointment.

Note that parent or legal guardian consent is required to proceed. 

For individuals under 18, you must include parent or legal guardian details in the Emergency Contact Information section below. 

Please also ensure that the primary parent or legal guardian completes the signature field at the end of the form.

If the person named in this form is aged 18 years or older, please complete the Intake Form For Adults at the following link: https://wisepsychologyptyltd.snapforms.com.au/form/wp--intake-form---individual

By providing these details, you consent, when possible, for Wise Psychology as a courtesy to submit claims on your behalf in the full knowledge that should a claim for a third party not be accepted that the client receiving the service is liable for the associated costs and not the third party.

For this form, the 'primary parent/guardian' is the 'parent/guardian' who assumes responsibility for arranging appointments and paying invoices.

By providing these details, you consent to being contacted when deemed clinically necessary by your child's practitionerin the event of emergency or as a non-primary contact when the primary contact cannot be contacted directly. 

You acknowledge that all listed parent/guardians may be contacted and therefore result in disclosure of the existence of the treatment of the child names on this form.

Complete these fields if there is a second parent/guardian involved in the treatment.

By providing these details, you consent to being contacted when deemed clinically necessary by your child's practitionerin the event of emergency or as a non-primary contact when the primary contact cannot be contacted directly. 

You acknowledge that all listed parent/guardians may be contacted and therefore result in disclosure of the existence of the treatment of the child names on this form.

After submitting this form, a senior practitioner will phone you to introduce themselves and schedule your first session. Please select as many of the following options as possible for them to contact the primary contact listed above.

For specific times, choose from the options below:

Dear parent/caregiver/primary carer/legal guardian,

Working with young people presents certain issues and legislation that psychologists must adhere to. The following clarifies where our practitioner's role as a Psychologist starts and ends. It also outlines our ethical and legal responsibilities regarding working with young people. 

A young person is defined as "someone under the age of 18 years old". A client-parent (or parents) is "the person who engages the psychologist to provide a psychological service for a young person". 

Whilst we do our best to communicate with the client-parent regarding the progress of the young person in counselling, we cannot disclose any personal information unless we gain a written consent from the client, i.e. "the young person". If they are deemed too young to understand these terms, disclosure to the client parent can occur. 

As the primary parent/guardian I give permission for the child listed on this form to attend ongoing appointments without my presence. I understand that there may be times I will still be required to be available via preferred mobile/telephone number and/or email for communication about their treatment and progress with treatment.