River Psychology | Referral/Intake Questionnaire

Referral/Intake Questionnaire

Tēnā koe, please take a few moments to consider and respond to the following questions. This will help us to match the right therapist to you, and will help us to better understand your needs and how we can help. If you would prefer someone to contact you via phone or to set up a face to face (kanohi ki te kanohi), please put down your name and contact details and a brief message at the end of the form and a member of our team will be in touch within two business days of receiving your form.

Name

Date of Birth

Phone Number

Address

Please select the difficulties that have been bothering you

In your own words, can you please tell us a bit more about why you have gotten in touch with us:

Have you ever received a Mental Health diagnosis?

Please write it here if comfortable to do so:

Are you currently taking any medication for mental health reasons?

If so, which medication and for how long?

What is your identified Gender?

Which ethnicity/ethnicities do you identify with?

Do you identify culturally and/or spiritually with any particular groups? If so, please provide a brief description.

Do you have a history of self-harm?

If so, please note down how long it has been since the most recent occasion:

Have you ever attempted to take your own life?

Are you currently having thoughts of wanting to end your life?

Which characteristics are most important to you in considering a good therapist match? Select as many as apply to you.

If you selected other above, please tell us a bit more about your therapist preferences:

How often do you think you would like to commit to appointments?

Which day/s of the week would you prefer to have your sessions?

Are there any days/times you cannot attend appointments?

Would you like a member of your whānau, or a support person, to be present at your first meeting? (Please note that support people are welcome at any point in engaging with our service).

Is there anything else you think we may need to know?

Address

Message Sent.

Phone: 027 216 2096
Email: office@riverpsychology.co.nz

PO Box 14153, Five Cross Roads, Hamilton 3252