New Patient Clinical Information

First Name

Last Name

Email Address

If you have a psychologist, please mention their name and their clinic's name below

If you any other allied health professional e.g. occupational therapist involved, please mentioned their name and their clinic's name below.

If you have specialists (e.g. cardiologist, neurologist), please mention their name and their clinic's name below

As far as you can remember, please provide list of past medications tried including the doses, side effects and reason for discontinuation

As far as you can remember, please list psychological treatments tried in the past. Please mention the name of the therapists you saw.

If you were ever admitted to an psychiatric inpatient unit (public or private), please provide details (when, which hospital, duration of stay, treating psychiatrist's name etc).

If you received Transcranial Magentic Stimulation (TMS), Electroconvulsive Therapy (ECT), Ketamine/Esketamine or any other specialists interventions for mental health, please provide details below.

Please mention any other information that you may feel would be useful for your consultation