Client intake form (screener)

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Complete Intake Form Below

Are you currently needing immediate care or in crisis right now? *

YesNo

Understanding Crisis

A crisis can manifest in various ways, including:

Suicidal Thoughts: Having thoughts of suicide and an intention to act on them within four weeks.
Self-Harm: Experiencing serious self-harm thoughts and intending to act on them within four weeks.
History of Attempts: Current suicidal thoughts combined with a history of previous attempts.
Housing Instability: Not having stable accommodation.
Present-Moment Challenges: Difficulty being present and feeling overwhelmed, leading to struggles in communication and logical thinking.
Threatening Situations: Being involved in life-threatening circumstances or domestic violence.

If you or someone you know is experiencing a crisis, it's important to seek help from a crisis professional or a support hotline. You’re not alone—support is available!.

The following agencies and numbers may be able to help in case of crisis:
Kids Helpline (for your child to use): 1800 551 800
Child and Youth Mental Health Services After Hours: 3716 8111
Brisbane Children's Hospital: 3068 1111
Parentline: 1300 301 300
13Healthchat: with a nurse 24 hours 13 432 584
Child Safety: A/H 3235 9999 / 1800 177 135
Child Health line: 3862 2333 / 1800 177 279
Disability Gateway: 1800 643 787
Lifeline: 131114
1300 MH CALL: Mental health access line: 1300 642255
Suicide Call Back Service: 1300 659 467
Beyond Blue: 1300 22 46 36
MensLine Australia: 1300 78 99 78
QLife (LGBTI): 1800 184 527
youthbeyondblue: 1300 22 46 36

Unfortunately we do not provide Psychiatry services or issue medication at Happy Brain.

Funding Type *

Unfortunately we do not provide Bulk Billing services at Happy Brain

Person Intending to receive the service

Are you enquiring for yourself or on behalf of someone else? *

Please complete the profile questions for the person intending to receive the service

Please complete the profile questions below

Is this person a Child or Adult?

Are you the consenting adult with legal rights to seek assistance for a child or minor? *

Unfortunately we are not able to talk to you about this person without written consent from a consenting adult. Please feel free to give us a call if you are not sure or wish to discuss this matter further.

Name *

Address *

Phone Number *

DOB *

Emergency Contact

Please complete the emergency contact details

Emergency Contact Name *

Emergency Contact Address *

Emergency Contact Phone Number *

Relationship to client *

Total score A

Questions

Total Score B

Total Score of A and B

Do you have any concerns or reservations about attending therapy?

Please read carefully

Happy Brain Fee Schedule

Therapy

Clinical Psychologist $250 (50 minutes)
General Psychologist $220 (50 minutes)
Provisional Psychologist $160 (50 minutes)
Play Therapist $226.23 (70 minutes)
Mental Health Care Social Worker $193.99 (50 minutes)

Assessments
Psychological/ assessmentsrange from $1,700 - $3,200 ( Not Medicare rebatable unless you have a referral from a Pediatrician or Psychiatrist requesting diagnostic assessment)

NDIS Clients
Refer to the NDIS price guidelines here - https://www.ndis.gov.au/providers/pricing-arrangements

I agree to Happy Brain's fee schedule *

Please confirm the person completing this form is 18 years and older? *