PsycHealth Book Now

This form is completely confidential

We will guide you through a series of questions to work out the type of support that is right for you and let you confidentially choose a practitioner that suits you.

What service do you require? *

EAP - Employee Assistance ProgramWorkCover, WorkSafe or Workers CompensationTAC (Vic), i-CARE (NSW) or any other motor vehicle accident psychologyGeneral Psychology - MedicareGeneral Psychology - Private insurance or self funded

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firstname *

surname *

Mobile number *

email address *

Emergency contact details (name, relationship, phone number) *

Emergency contact details

City *

State *

Country

AustraliaNew Zealand

Gender *

FemaleMaleNon‑binaryAnother gender identityPrefer not to say

Date of Birth *

Medicare name (exactly as it appears on card including any initials) *

Medicare number *eg 1234 56789 1

Medicare IRN number *It's the number infront of your name eg. 1 JOHN SMITH

GP (Doctor Name) *

GP Provider number *eg 1234567A or 123456AB

GP (Doctor) Clinic name and address, phone, email and fax *It's the number infront of your name eg. 1 JOHN SMITH

File Upload GP Mental Health Care Plan

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If you have difficulties please email it to info@psychealth.com.au or fax (03)99789456 or call Mandy on 0480 416 189

WorkCover Insurer? *

TAC (Vic), i-CARE (NSW) or any other motor vehicle association *

WorkCover Claim number and claim manager *

Claim number and claim manager name *

What company do you work for? *

Subdivision branch or location *

Your GP (Doctor) Name, Clinic, Phone

Are you experiencing (optional)

AnxietyDepressionGrief & lossPanic attacksStressbullyingRedundancyWork PressuresOther

How Does This Impact The Clients Daily Life (optional)

File upload eg. GP correspondance (optional)

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Any notes or message to practitioner (Confidential)

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