Please complete the form below to help me understand your needs and to determine whether we are a good fit.

All information is kept confidential and treated with care.

Personal Details

First Name

Last Name

Email

Emergency Contact and Name

Gender / Pronouns (Optional)

Appointment Preferences

How would you like to attend your session?

In Person at the Cosmos Co, Anambah NSW

Telehealth (Online)

Open to either

Which type of session are you enquiring about?

Psychology Session

EMDR Session

Breathwork Session

What is your preferred time of day for a session?

Morning

Midday

Afternoon

Therapy Focus and History

What are your primary reasons for seeking therapy at this time? (You’re welcome to write in as much or as little detail as you feel comfortable sharing.)

On a scale of 1 to 10, how would you currently rate your overall level of stress or emotional overwhelm? 1 = low, 10 = extremely high

Have you previously worked with a psychologist?

Yes

No

Have you ever received a mental health diagnosis?

Yes

No

If yes, please specify (diagnosis, treatment, timeframe):

Are you currently taking any medications?

Yes

No

If yes, please list them and what they’re prescribed for:

Any medical conditions we should be aware of?

Any history of substance use or addiction?

Yes

No

If yes, please provide details

Do you currently feel safe and supported in your day-to-day life?

Yes

Mostly

No

Do you have a support system (friends, family, community, groups)?

Yes

No

Are you currently experiencing thoughts of self-harm or suicide?

Yes

No

If yes, please share anything you feel comfortable disclosing. This helps us ensure your safety and support.

Referral and Medicare Fees

How did you hear about me?

Do you have a Mental Health Care Plan (MHCP) from your GP?

Yes

No, but I will get one

No, will be a private client

Do you have private health insurance?

Yes

No

If yes, please provide your provider

Please note: My fee is $240 for the first session and $220 for all subsequent sessions, Medicare rebates are available with a valid MHCP.

Private health rebates may apply depending on your fund and level of cover.

Do you understand and accept the session fees?

Yes

No

Consent

I consent to my information being reviewed and to being contacted regarding appointments.

Yes

I acknowledge that I have provided accurate and complete information to the best of my knowledge.

Yes