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Client details
Client's name
*
First name
Last name
Preferred name (if different from above)
Gender
Personal pronouns
She/her, he/him, they/them, xem/xer, etc.
Date of Birth
Diagnosis (if applicable)
Ethnicity
Email address
*
Please enter the preferred email for correspondence
Phone number
*
Please enter the preferred phone number for contact
Preferred contact method
Email, call, or text?
If we call, can we leave a voicemail message?
No
Yes
Emergency Contact Details
Emergency Contact Name
Relationship to Client
Phone number
Leave blank if one primary phone number or enter a landline or other relevant number.
Email
leave blank if email as above or enter a second email address if relevant
Other professionals
Are you working with any other health professionals (eg. therapist, psychiatrist, doctor)?
No
Yes
If you consent to information sharing between DTNZ and the provider, please provide their professional title, name, and contact details.
Are you an ACC ISSC Sensitive Claims client?
Tick if 'yes', leave blank if 'no'
Are you seeking ACC ISSC Sensitive Claims cover?
Tick if 'yes', leave blank if 'no'
Other information
Reason for referral
Hoped for outcome
Conditions that therapist needs to be aware of
(unsafe household environment, health concerns, etc).
Medication
No
Yes
Medication details
Relevant strengths or difficulties
Languages spoken
Preferred modality
(Dance/Movement Therapy, Art Therapy, Combined Creative Arts Therapy)
Preferred mode of delivery: in-person, online, or both?
DTNZ prefers to deliver sessions in person where possible, however online is an option.
Are you open to group therapy?
Are you open to individual therapy?
Where did you hear about DTNZ?
Group
Inquiries
Please check the highlighted fields
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