Preliminary Information Form Please fill out the following form before your first appointment * indicates required field PERSONAL DETAILS Name:* Email:* Date of Birth:* Phone Number:* YOUR GP'S DETAILS GP Name:* Contact Number:* EMERGENCY CONTACT Contact Person:* Emergency Number:* Relationship:* Depression Anxiety Stress Scales (DASS) form Please download and complete this DASS form no more than a week prior to attending your first session. If filling out this form distresses you please contact Peter Langdon on 0409954707 or Life Line on 131 114. Upload form here: Acceptable file types: pdf, jpg, jpeg, png, doc, docx, gif.Maximum file size: 1mb. Terms of Service I agree to the terms below:* Psychological Services Agreement Psychological services provided by Peter Langdon – Registered Psychologist are counselling and assessment to provide treatment for your specified condition or situation. Individual goals and treatment strategies will be discussed and written up as a service plan. This is usually reviewed after 6 sessions or at a point of need or concern. Information collection In providing psychological services to you, Peter Langdon, will need to collect and record personal information that is relevant to your current situation. This is part of the assessment and treatment plan, of which you will be informed of the nature and content of your personal record. Confidentiality All personal information gathered by the psychologist will remain confidential and secure, except where: 1. The file is subpoenaed by court; or, 2. Failure to do so would place you, or another person at serious and imminent risk; or, 3. Your prior approval has been obtained to discuss your case with other concerned parties: eg: GP, Allied Health Professional, Lawyer, TAC, WorkSafe, Guardian, or other family members. Fees and cancellation policy Accounts are to be settled on the day of consultation unless otherwise specified. If you need to cancel your appointment time, 24 hours notice would be appreciated – otherwise a $60 fee will be charged. CAPTCHA Code:* Leave this field empty