Intake Form (Child/Adolescent)

Please note, for clients under 12-years of age we will generally have a parent-only initial session to be able to facilitate a comprehensive assessment of current issues and relevant history.

Therapy sessions are charged at $180 per 50 minutes, with a discounted rate available for concession and DVA card holders. For clients with an eligible Mental Health Care Plans, there is a Medicare rebate of $85.20 (out of pocket $97.50) for 10 sessions per calendar year. Speak to your child’s doctor about a plan.

You may be charged a short-notice cancellation fee if you do not provide at least 2 business days cancellation notice for the agreed service. For appointments booked at an alternative location, you may also be charged travel time if you do not attend within 30mins of the scheduled appointment. Refer to our Cancellation Policy for more information.

Full payment is required at the time of the appointment, except for NDIS clients who are plan-managed. Stakeholder liaison, report writing and resource development is charged at the same hourly rate.

Confident Horizons is committed to ensuring your privacy and will maintain the highest level of confidentiality. Information disclosed during therapy sessions will only be shared if permission is granted by the client, or in circumstances related to duty of care and legal obligation. Please refer to our Privacy Policy for more information.

We use a platform called Heidi to record clinical notes during sessions. This allows us to focus entirely on you during your visit while still allowing a comprehensive and precise record of your care. All information is de-identified and encrypted and Heidi complies Australian Privacy Principles and the Privacy Act. You can find more information about Heidi on this factsheet or via their website. Please speak to your therapist if you have any concerns.

Once you submit this form, we will be in touch to confirm your initial appointment.

Client's Name:

First Name

Last Name

Client's Date of Birth:

YYYY

Client's Preferred Name / Pronouns (she/he, her/his, they/them):

Client Email (if applicable)

Client Phone (if applicable)

(###)

###

####

Parent's Name:

First Name

Last Name

Other Parent's Name:

First Name

Last Name

Parent's Phone (primary contact):

(###)

###

####

Parent's Email:

Parent's Date of Birth (if you would like us to process Medicare claims directly):

YYYY

Client's Medicare Number:

If you have a GP referral and provide your Medicare number, we can process the Medicare rebate directly.

Client's Medicare Reference #:

Parent's reference # on Medicare Card:

Client's Health Care Card Number (if applicable):

Residential Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

General Practitioner (Name + Practice):

Reasons for Coming to Confident Horizons?

What are some of the goals of engaging in therapy?

How did you hear about Confident Horizons?