Client Intake - Ethos Psychology

Who is this form for?

Who are you completing this intake for? *

Your details as the person submitting

If you are completing this form for someone else, add your details here, explain your relationship to the applicant, and confirm that you have consent to share their information.

Your full name * Your email * Your phone * Relationship to the applicant *

Client details

These details should be for the person seeking support.

Full name * Preferred name Date of birth * Phone * Email * Address Street address * Employment status

Funding and service background

Client type *

Privately funded ACC sensitive claims Organisationally funded / professional development Health insurance / Medical coverage WINZ support Other

Is this your first time engaging in psychology services? *

Yes No

Presenting concerns

Do you experience any of the following? (Please select all that apply)

Seizures Panic attacks Manic episodes Excessive risk-taking behaviours Thoughts or urges to self-harm Suicidal thoughts or intent

Anything else you would like Ethos to know?

Emergency contact information

Emergency contact full name and relationship to you * Their best contact number *

Consent

Begin your intake with clarity and care

Ethos Psychology client details