Appointment request form

Seeking support for your mental health is a courageous first step and telling us about your current situation and experiences will help us assist you in finding the right help for your current needs. The information you provide below is treated in strict confidence and allows us to determine whether our psychology practice is the right fit to support your needs.

General Information

First Name *

Last Name *

Pronouns

Date of birth *Please note, ME Health Clinic is currently only accepting referrals for individuals aged 18 and older.

Phone number: *

Email Address *

Are you accessing the service for perinatal support (i.e., support during pregnancy up until 3 years post-birth)?

YesNo

Please state weeks of pregnancy and/or age of infant

Clinical information

Please tell us a bit about your current situation and why you are accessing therapy.

Please provide further detail below (if needed) and list any previous and/or current mental health diagnoses:

I am currently taking medication for my mental health *

NoYes

Please list current medications:

Please list any other health professionals currently involved:

In the past, I have seen the following mental health professional(s) or required the following mental health services

Please specify:

I currently consume alcohol excessively or use illicit drugs *

NoYes

I have been admitted to a hospital in relation to my health in the last 12 months *

No Yes

I have at least one person who supports me emotionally *

NoYes

In the past two weeks, I have (select all that apply) *

Had thoughts to harm myselfHad thoughts of suicideHad thoughts to harm a childFelt scared within my home due to violence, threats or controlling behaviourFelt scared someone will harm my childNone of the above

I am currently linked in with the following services for my care (select all that apply): *

Please list other services involved in your care:

Please specify:

Next steps

You will shortly receive a confirmation email and a call from our team over the coming days. We ask all new clients to speak with us during an initial 10–15-minute telephone call. This is an opportunity to answer any questions you may have, and the reasons you are seeking support from the ME Health Clinic team. We look forward to speaking with you soon.