Under 18 Client Information

Under 18 Confidential Client Information

Child's Details

Child's Surname*

Child's First Names*

Child's Address*

Child's Post Code*

Date of Birth*

Child's Age*

Parent / Guardian Information

Parent / Guardian Surname*

Parent / Guardian First Names*

Parent / Guardian Relationship*

Parent / Guardian Address*

Parent / Guardian Post Code*

Parent / Guardian Date of Birth*

Parent / Guardian Email*

Parent / Guardian Home Phone

Parent / Guardian Work Phone

Parent / Guardian Mobile*

Medicare Details

If child is utilising a Mental Health Plan, please provide Medicare details for child and claimant.
All 3 fields are required (card number, patient reference number, expiry date).

Child Medicare Details

Child's Medicare Card Number

Patient Reference Number

Medicare Expiry Date

Claimant Medicare Details

Claimant Name

Claimant Medicare Card Number

Patient Reference Number

Medicare Expiry Date

Other Details

Are there any court orders in place for this child? If so, a copy will need to be supplied prior to session*

Yes

Authorised contacts

May we send you an appointment reminder via SMS?*

Yes

How did you hear about us?

Other

Under 18 Confidential Client Information

Child's Details

Parent / Guardian Information

Medicare Details

Other Details

crookes counselling & consulting services

Werribee