Pre-Assessment Questionnaire
Purpose

It is wonderful that you have chosen to engage with a clinician at Eat Love Live. 

This form is optional, but has been designed with two purposes in mind:

  1. Firstly, if you are unsure which practitioner would be the right fit for you, our Clinical Director and client service team will review the information you have provided and make suggestions.
  2. Secondly, this is an opportunity for you to provide information to the clinician you have chosen to make an appointment with. There may be lots of information you wish to share and are worried it won't all be covered in the initial session - or that you may forget something. 
Reflecting on your answers before the session may help you to develop a clearer understanding of the goals you would like to work on with your clinician.

If you are worried that reflecting on your medical, dietary or mental health history may be distressing or triggering in any way, please know that it is ok not to fill in this form. The information can all be gathered by your practitioner in the initial consultations in a supportive manner to avoid undue stress.

Privacy

This form will only be viewed by our Clinical Director and  our client services team for the purposes of triage or allocation to the correct file.  This form will then be stored in your medical record and viewed only by your practitioner. 

You will complete a New Client form prior to your session which will gather all the relevant personal information. This will be provided to you by reception and includes further information about privacy and confidentiality.

Referrals

If you have a referral from your GP you can forward this to reception@eatlovelive.com.au however you do not need to have a referral to make an appointment.

Please note this form does not act as a booking.


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Email *
Name *
First and last name
Date of Birth: *
Phone:     *
Address:
Which gender do you identify with?
Clear selection
Gender, self describe
What pronouns are best for you?
Will you be using NDIS funding to support the payment of appointment fees? 

Please note Eat Love Live charges for services provided in line with our scheduled fees which reflect that you are accessing a specialist, private service. Eat Love Live is not a registered NDIS provider.

NDIS clients will incur, and must agree to cover, an out of pocket/gap fee (OOP/GAP fee) to meet Eat Love Live’s standard fees as a private practice.

Accepting NDIS participants is at the discretion of each clinician based on their individual capacity. Each clinician's ability to support new NDIS clients is stated on their clinician profile page (alongside their ability to accept new clients at this time) as well as the clinician table on our Book an Appointment page.

Please refer to our  NDIS Fee Schedule for further information or call reception on (03) 9087 8379.
 *
Do  identify as neurodivergent 
Clear selection
If you would like to share you can list the neurodivergent  identities you connect with below:
Please include any accessibility needs you have that are important for us be aware of to support you. 

Which type of practitioner would you like to see ? (Tick as many as appropriate)
Clear selection
Which practitioner would you like to see at Eat Love Live? Please leave blank if unsure.
Session type preference
Clear selection
Our clinicians primarily practice Monday to Friday during standard business hours, with some after hours appointments available. To avoid suggesting clinicians whose practice hours don't align with your availability, please select any of the following that apply to you:  
Would you like a suggestion of which health practitioner at Eat Love Live may be a good fit for you based on the information provided in this form? 
Why are you interested in seeing a dietitian,  physiotherapist or Eating Disorder Carer Support Specialist at Eat Love Live?
Were you referred by a practitioner? If so who?
If not, how did you find Eat Love Live?
Have you seen a dietitian,  physiotherapist or  Eating Disorder Carer Support Specialist  before? What was helpful/ unhelpful about this process in the past.
Please briefly describe your medical history.
Please briefly describe any mental health history.
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