New Client Intake Form

New Counselling Client Intake Form

Should you wish to proceed with our services, please fill out the following new client intake form . We need to receive your signed intake form prior to your first appointment in order for us to get more information about you and for our counsellors to know how they will be able to best help you.

Your preferred initial session schedule will be confirmed once we receive your intake form.

Thank you.

Client Details

Client Name (Last, First Middle Initial

Are you a participant of the NDIS? If yes, please indicate your NDIS No. below. If not. write N/A.

Add your plan manager

Birthdate DD-MM-YYYY

Age

Name of parent or gurdian if under 18

Pls list any children/age (or N/A if not applicable)

Address (street, number), (city, state, zip)

Home Phone

* please note, email correspondence is not considered to be a confidential medium of communication.

Other Phone

Previous Therapist/Practitioner

Referred by (if any)

Please list

Please list and provide dates

General Health and Mental Health Information

Pls list any specific health problems you are currently experiencing.

Pls list any specific sleep problems you are currently experiencing.

3. How many times per week do you genrally exercise?

What types of exercise do you participate in?

4. Please list any difficulties you experience with your appetite or sleeping patterns.

If yes, for approximately how long?

If yes,when did you begin experiencing this?

If yes, please describe.

If yes, for how long?

11. What significant life changes or stressful events have you experienced lately?

Family Mental Health History

Please answer and list family members.

Family member

Additional Information

Describe your current work situation. Do you enjoy your work? Is there anything stressfull about your work?

If yes, describe your faith or belief.

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

5. What would you like to accomplish out of your time in therapy?

Disclosure Form

Mode of Payment and Cancellation Policy

Limits of Confidentiality Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows: *Duty to Warn and Protect When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. *Abuse of Children and Vulnerable Adults If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. *Prenatal Exposure to Controlled Substances Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. *Minors/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records. *Insurance Providers (when applicable) Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.

Mode of Payment For clients who are paying * privately, we accept direct deposit, EFTPOS (debit and credit cards) and Afterpay * via Private health fund (BUPA, Medibank, St Lukes, Police fund, Phoenix), we require full payment upfront and we issue a sales receipt upon completion of payment that you may use to reimburse with your health fund provider. * via Medicare Mental Health Care Plan (MHCP), we require a gap payment of $80 and we coordinate directly with your GP * via NDIS, sessions are covered by the NDIS, depending on client’s plan. Cancellation Policy If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment. A full session fee is charged for missed appointments or cancellations with less than a 24-hour notice unless it is due to illness or an emergency. A bill will be mailed directly to all clients who do not show up for, or cancel an appointment.

I agree to the above limits of confidentiality, mode of payment and cancellation policy and understand their meanings and ramifications. please affix your signature at the space provided or tick the checkbox to indicate your acceptance of the terms and conditions.

Full Name

Please sign here

Date Signed

I accept the terms & conditions

Thank you for sending us your intake form. Our counselling team will be in touch to coordinate your initial session.