Contact Us

We'd love to hear from you.

This form doubles as our confidential intake questionnaire, so there's just one thing to fill in — whether you're getting in touch for the first time or preparing for an upcoming appointment. The information you provide helps your psychologist understand your concerns, plan appropriate support, and tailor your assessment or treatment.

You do not need to answer every optional question. Anything you would prefer to discuss in person can be left blank.

Fields marked with an asterisk are required.

Client Information

Full name

Preferred name

Date of birth

Age

Calculated from date of birth

Phone number

Email address

Please provide at least a phone number or an email address so we can contact you.

Address

Gender

Pronouns

Emergency contact

Name

Relationship

Phone

Reason for Referral

How did you hear about us?

Who referred you?

Have you previously seen a psychologist or therapist?

Yes No

Mental Health History

Have you ever been diagnosed with a mental health condition?

Yes No

Have you ever been admitted to hospital for mental health treatment?

Yes No

Medical History

Current medical conditions

Current medications

General Practitioner (GP)

Support Network

Who are the important people in your support network?

Do you generally feel supported by family or friends?

Yes Somewhat No

Personal Strengths

What strengths help you cope with difficult situations?

What activities, hobbies or interests bring you enjoyment?

Therapy Goals

What would you like to achieve through therapy?

Risk and Safety

These questions help your psychologist understand how best to support you.

If you are in crisis or at risk of harming yourself, please don't wait for a response to this form. Call or text 1737 (free, 24/7), call Lifeline on 0800 543 354, or in an emergency call 111.

Have you experienced thoughts that life is not worth living?

Never Occasionally Frequently

Have you had thoughts of harming yourself?

Yes No

Have you ever attempted suicide?

Yes No

Do you currently feel safe?

Yes No

If you answered "No" or would like to discuss your safety, please let your psychologist know as soon as possible.

Additional Information

Is there anything else you would like your psychologist to know before your first appointment?

Consent

I confirm that the information provided in this questionnaire is accurate to the best of my knowledge.

Type your full name to sign

Health Professionals

Referring a patient? Use our dedicated referral form to provide clinical details and we'll be in touch promptly.

Make a referral

Before you begin

This form helps us prepare for your first appointment.
You can skip optional questions.
Required fields are marked with an asterisk *.
Your information is treated confidentially.

Time to complete

Approximately 15–20 minutes

Your privacy

Your information is stored securely and is only accessible to our clinical team.

Visit us

Brain Health Nelson
1a Wainui Street
Nelson City
New Zealand

NZ HPI Facility ID: F3V630-F

Need urgent support?

If you are in crisis or need immediate assistance, please call 111 or contact 1737 (free call or text) for 24/7 support.

Your information is secure and confidential

Contact Us

Client Information

Reason for Referral

Current Concerns

Current Symptoms

Mental Health History

Medical History

Alcohol and Substance Use

Sleep and Lifestyle

Family Mental Health History

Social History

Support Network

Personal Strengths

Therapy Goals

Risk and Safety

Additional Information

Consent