Date

MM

DD

YYYY

I would like to:

Refer myself as a client.

Submit an intake form on behalf of a family member or friend.

Submit a intake form on behalf of an organisation

Please select one of the following

Parent/Family Member

Support Coordinator

Carer/Guardian

Other Professional

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Name

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Will this person be accessing Expressive Arts Therapy as part of their NDIS Plan?

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Preferred Method of Communication

Phone

Email

Text

In-Person

Third Party (person named above)

How is your general physical health?

Poor

Fair

Good

Excellent

Have you been hospitalised for mental health, substance abuse or emotional health issues in the past 5 years?

Yes

No

Unsure

Are you currently experiencing suicidal thoughts?

Yes

if yes, do you have a plan?

No

Sometimes

Rarely

Never

Plan Management

Self-Managed

Plan- Managed

NDIS/Agency Managed

Name

First Name

Last Name

Phone

(###)

###

####

Name *

Please print your name

First Name

Last Name

Date

MM

DD

YYYY