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02 9054 7830
Request Appointment

Home
Locations
- Castle Hill
- Longueville
Services
Team
- Meet Our Team
- Join Our Team
Services
Telehealth
Blog
Resources
- Online Resources
Contact
02 9054 7830
Request Appointment

Psychiatry Child/Teen (17yo & under) Enquiry Form

Client Details

Client Name

First Name(Required)

Last Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Gender

What are the correct pronouns?

Address

Street Address(Required)

Address Line 2

Suburb(Required)

State(Required)

Postcode(Required)

School(Required)

Year(Required)

Parent / Guardian Details

Parent / Guardian Details(Required)

Couple

Separated

Other

Do you have court ordered custody arrangements?(Required)

Yes

No

Do you anticipate both parents will be involved in the child's treatment?(Required)

Yes

No

Do you have domestic violence related intervention orders in place?(Required)

Yes

No

Please specify(Required)

Parent/Guardian 1

First Name(Required)

Last Name(Required)

Relationship to Client(Required)

Contact Number(Required)

Email Address(Required)

Parent/Guardian 2

First Name

Last Name

Relationship to Client

Contact Number

Email Address

Reason for Appointment

Select reason for appointment (please select up to 3 of the most concerning to you).
This information will help us understand what your child's needs are.

Select reason for therapy(Required)

Anxiety or excessive worry

Low mood, depression, or withdrawal

Attention, concentration, or hyperactivity difficulties (e.g. ADHD symptoms)

Aggression, defiance, or behavioural outbursts

Self-harm, suicidal thoughts, or emotional dysregulation

Obsessive thoughts or compulsive behaviours (e.g. OCD symptoms)

Social difficulties or peer relationship concerns (e.g. bullying, isolation)

Learning or academic concerns (e.g. difficulties with school performance)

Autism spectrum traits (e.g. social communication differences, restricted interests)

Sleep, appetite, or toileting concerns

Family stress, conflict, or parenting challenges

History of trauma, abuse, or exposure to family violence

Substance use or risk-taking behaviours

Grief, loss, or adjustment to major life changes

Additional information

Please list any assessments, interventions and therapies that have already been tried, including any medication or other treatments that are ongoing.(Required)

Current home situation(Required)

Has the client seen a psychiatrist before?(Required)

Yes

No

Is the client currently under the care of a paediatrician?(Required)

Yes

No

General Information

How did you hear about us(Required)

Policy

Cancellation - We ask that clients contact the clinic no later than 48 hrs before your appointment if you are unable to attend, please cancel at your earliest opportunity via phone, text or email so that the appointment can be made available to others. In the event you don’t, a cancellation fee will be incurred. This policy is explained during intake and at the initial appointment with your psychologist.

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Request Appointment

Castle Hill Clinic

info.CH@sydneypsychhub.com.au

Suite B, 8 McMullen Avenue,
Castle Hill, 2154 – Get directions

Longueville Clinic

info.LV@sydneypsychhub.com.au

Tenancy G-25, 4 Northwood Road,
Longueville, NSW 2066 – Get directions

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