New patient intake

Please complete this form before your first appointment. It takes about five minutes, and having it in advance means your consultation time is spent on what matters. Fields marked * are required.

Leave this field empty

About you

Given name *

Surname *

Date of birth *

Medicare number

DVA number

Phone *

Email *

Address

Emergency contact

Your referral

Referring doctor *

Practice / clinic

Practice phone

Practice fax

Referral date

Practice address

Is your regular GP different from the referrer?

Upload your referral letter

📄

Attach your referral letter

PDF, JPG, PNG or Word document · max 10 MB

📎

If you don't have a copy, your referrer can fax or email it to us — just continue without attaching.

Clinical background

What would you like help with? *

Current medications

Allergies or medication reactions

Previous psychiatric or psychological care

✓

Thank you — received

Your intake has been securely submitted and will be reviewed by Dr Harwood before your appointment. You don't need to do anything further. If your plans change, please use the link in your booking confirmation to reschedule.

Trypta Private Psychiatry · Dr Ben Harwood FRANZCP
trypta.health · ben@trypta.health
Your information is transmitted encrypted and stored in Australia.