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NeuroAct Initial Questionnaire
Please complete this initial questionnaire when booking your call so I have a better understanding of your situation prior to our call. Thank you. - Vivian
Email Address
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Date Today
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NeuroAct Program Start Date:
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NeuroAct Program Start Date:
A
Teens (13-17): Thursdays 21st Aug 2025 - 6th Nov 2025 @ 4.30-6pm NSW Time
B
Adults (over 17): Thursdays 21st Aug 2025 - 6th Nov 2025 @ 6.30-8pm NSW Time
C
Others
Teen/Adult Name
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Gender
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Specify any preferred pronoun
Date of Birth
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Age
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School and Grade/Uni/Work
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Where did you hear about us?
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Parent/Carer Name:
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Address:
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Mobile:
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Diagnosis (if any):
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Meds (if any):
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Type of School Setting (if applicable):
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Major mental illness (schizophrenic, bipolar). Specify
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Physical disability of relevance. Specify
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What else would you like me to know?
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Submit
