Form cover
Page 1 of 2

NeuroACT Intake Form - Adults

The following information will allow us to better help you.

Please answer all items CLEARLY.

ALL INFORMATION PROVIDED WILL REMAIN IN THE STRICTEST PROFESSIONAL CONFIDENCE

Name

First Name and Last Name

Gender

Date of Birth

Age at start of course

Mobile Number

Address

Home Address/Suburb/Postcode/State

Email Address

Name of Parent/Carer (if applicable)

Email Address of Parent/Carer (if applicable)

Mobile Numbers of Parent/Carer (if applicable)

Diagnoses

Diagnoses
A
B
C
D
E
F
G
H
I
J

Lifestyle Changes/Psychosocial Stressors

(past 6 months-1 year) – check all that apply
Lifestyle Changes/Psychosocial Stressors
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O

NEUROACT PLANNED ABSENCE SHEET

It is very important for you to attend every session of NeuroACT. However, if you know that you have to be absent for a session, please mark those dates that you know that you will not be able to attend below.

Advance information about planned absences will be used to determine if a particular session needs to be rescheduled based on the anticipated number of absences.

Session/Date/Planned absence:

NEUROACT CONFIDENTIALITY AGREEMENT

It is our highest priority to create a safe, compassionate and confidential environment for our NeuroACT participants. We therefore require each participant sign a confidentiality agreement prior to starting the program.
The issue of confidentiality is a shared responsibility, so each member of the group bears that responsibility.
Please read the statement below and sign to show your agreement.
I agree to protect the confidentiality of the group and not share information about any
NeuroACT participant with other people outside of this NeuroACT group.
Name (Print):

NEUROACT CONFIDENTIALITY AGREEMENT

Participant's Signature:
Signature

NEUROACT CONFIDENTIALITY AGREEMENT

Date Signed: