Parent/Carer Questionnaire for New Child Clients


Child's Name *
Child's Name
Date of Birth *
Date of Birth
Carer 1
Relationship to Child *
Carer 2 (if applicable)
Relationship to Child
Child's Medical History
Does your child have any medical conditions? *
Does your child take any prescribed medication? *
Does your child have a GP Mental Health Treatment Plan? *
Do you intend to claim a Medicare rebate for your sessions?
Eg. Difficulty with reading, spelling, numbers
Prior psychological treatment
Has your child ever seen a psychologist before? *
Eg. child’s age at time, name of professional, age, reason for referral
Prior Assessments
Has your child undergone any assessments before (e.g. cognitive, occupational therapy, speech pathologist)? *
Please bring any reports to your first appointment.