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.

Location of Service *

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?

Name *

Preferred name?

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.

Address *

Phone Number *

DOB *

Are there any communication or language differences that we should be aware of?

Do you have familly court orders in place?

YesNo

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

Court or Parenting Orders Check

Do you have any court orders that affect your family? Court orders are official legal documents from a judge that tell families what they must do.

If you do have court orders:

Please send a copy to intake@happybrain.com.au - we need this for our files
If these are family court orders (about custody, living arrangements, etc.), you also need to fill out a Happy Brain Seperated Family form before getting support from Happy Brain professionals

Next Steps:

Click this link to Watch the Seperated Family Video (opens in new tab).
Click this link to complete the form: Happy Brain Seperated Family Agreement (opens in new tab).
After you finish the form, continue this form.

This helps us understand your situation better so we can provide the right support for your family.

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

Total K-5 Score

Do you have any concerns or reservations about attending therapy?

Please read carefully

Happy Brain Fee Schedule

Private & Medicare Therapy

Clinical Director $300 (50 minutes)
Clinical Psychologist $280 (50 minutes)
Senior Psychologist $265 (50 minutes)
General Psychologist $255 (50 minutes)
Mental Health Care Social Worker $235 (50 minutes)
Provisional Psychologist $220 (50 minutes)
Play Therapist $220 (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

Assessment Funding Questions:

Have you confirmed in writing from your plan manager that your NDIS funding is approved and available for a diagnostic assessment?
Have you had a chance to look at the cost of the assessment? Our assessments range from $1,700–$3,200 depending on what's involved. We want to make sure the timing works for you financially — are you in a position to go ahead, or would it be helpful to have a bit more time to plan for that?
Do you have your funding pathway confirmed — self-funded, NDIS self-managed, NDIS plan-managed, or Medicare referral from a Paediatrician or Psychiatrist?

I agree to Happy Brain's fee schedule *

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