Please note: items marked * indicate mandatory fields. Acknowledgement of Understanding I have read and understand the Your Appointment and Fees and Payment pages. I understand that all appointments are conducted via Telehealth (Video Conference). Yes, I acknowledge the above I have read and understand the Your Appointment and Fees and Payment pages. I understand that all appointments are conducted via Telehealth (Video Conference). Personal Details Title - None -MrMrsMissMsDrProfOther Preferred Title First Name Last name Preferred name Date of Birth Contact Details State - Select -NSWVICQLD Please note that the practice currently can only accept patients from NSW, VIC, and QLD due to state legislation reasons. Email Mobile Phone Please enter mobile number. No spaces please. eg. 0412345678 Private Patient Type - Select -With Medicare CardWithout Medicare Card Please note we are a private practice, and bulk-billing services are not offered. The practice does not accept workers compensation, CTP, NDIS, veteran affairs, or medico-legal patients. If applicable, please check with your General Practitioner (GP) for alternative options. Medical History Include diagnosed conditions that have previously affected, or currently do affect you. Select all that apply. Diagnosed Previous or Current Conditions ADHD Anxiety Autism Spectrum Disorder (ASD) Bipolar Disorder Chronic pain Depression Drug and / or alcohol problem Dyslexia Eating disorder Intellectual disability Learning disability Obsessive Compulsive Disorder (OCD) Panic attacks Personality issue or disorder Phobias Post Traumatic Stress Disorder (PTSD) / Trauma Psychosis Schizophrenia or Schizoaffective disorder None Other Other Diagnosed Condition Include conditions that you personally believe may have previously affected, or currently affect you. Select all that apply. Undiagnosed Previous or Current Conditions ADHD Anxiety Autism Spectrum Disorder (ASD) Bipolar Disorder Chronic pain Depression Drug and / or alcohol problem Dyslexia Eating disorder Intellectual disability Learning disability Obsessive Compulsive Disorder (OCD) Panic attacks Personality issue or disorder Phobias Post Traumatic Stress Disorder (PTSD) / Trauma Psychosis Schizophrenia or Schizoaffective disorder None Other Other Undiagnosed Condition Include conditions that you are currently most concerned about. Select all that apply. Primary Conditions of current concern Adult ADHD Anxiety Disorder Bipolar Disorder Depression Obsessive Compulsive Disorder (OCD) Post Traumatic Stress Disorder (PTSD) Other Other Condition of current concern Problems / symptoms – reason for appointment Desired outcome of treatment Personal Information Confirmation I understand that the personal information provided by this webform will be collected, held, and used in accordance with Nourishing Minds Psychiatry’s Patient Privacy policy. I confirm that I have read, consent, and agree to the Patient Privacy policy. This is in line with the Privacy Act 1988 (Cth) (‘the Privacy Act’) updated 2018. Yes, I confirm the above I understand that the personal information provided by this webform will be collected, held, and used in accordance with Nourishing Minds Psychiatry’s Patient Privacy policy. I confirm that I have read, consent, and agree to the Patient Privacy policy. This is in line with the Privacy Act 1988 (Cth) (‘the Privacy Act’) updated 2018. Referral We require an electronic copy of your referral (PDF preferred) to assess suitability for an appointment. Provide up to five relevant documents. Document Uploads Choose File(s) Provide up to five relevant documents (scanned referral, certificates etc). Maximum 5 files.3 MB limit.Allowed types: jpg, jpeg, png, doc, docx, pdf.15 MB limit per form. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
