Client Welcome Form Nationwide

Client Welcome Form Nationwide

ABN: 55 637 079 620
Take note: If a participant makes a short-notice cancellation, which is after 3pm the day before the service, the provider will charge 90% of the agreed price for the cancelled appointment.

For other cancellations, where the participant has provided notice of cancellation prior to 3pm the day before the scheduled service, no cancellation fee will apply.

To cancel, please call and email the head office at: (07) 4864 9888 | contact@empoweredtherapyandtraining.com
Therapy or service required (please tick all that apply):*

Art TherapyCounsellingPsychotherapyMusic/Dance TherapyDrumming TherapyLaughter TherapySandplay TherapyHypno-therapyTimeline TherapyDrama TherapyOther
Location of Service:*

Home VisitOfficeOther
Client/ Participant Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:*

FemaleMalePrefer not to sayOther
Home Phone Number*
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Children:*
Current Marital Status:*

SingleMarriedWidowedDivorcedRemarriedOther
Current Employment Status:*

Full-TimePart-TimeStudentStay-at-home parentNot Currently EmployedOther
Emergency Contact
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to you:*
How did you hear about us?
Referred by:*

Private/IndividualGeneral Practitioner (GP)OrganisationDOCSOther
Please provide the details of who referred you:
Starting date*

DayMonthYear
Date
How many sessions are you granted?*
What do you do in your spare time? Hobbies, interests, etc. *
Prior Life Experience
Which of the following have you experienced (either currently or in the past)? Please tick all that apply:*

Physical abuseDepressionParents separation/divorceDifficulty in intimate relationshipsAttempted suicidePhysical Health concernsDrug or alcohol abuseAnxietyPanic attacksSexual assault/abuseDeath of a close family memberConcerns about eating/foodMental abuseEmotional abuseSelf-harm abuseAddictionOther
Which of the above continue to be a problem for you?*

Please answer yes or no for the following:*

	Yes	No
Do you have current concerns about alcohol use?
Do you have concerns about illegal drug use?
Do you overuse prescription medication?
Do you have concerns with gambling?
Do you have concerns with excessive Internet use?
Do you have concerns with Internet porn use?
Do you have current thoughts of suicide or plans for suicide?
Have you ever attempted suicide?

Intensity of suicidal thoughts:

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Intent to carry out suicidal thoughts:

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
If you have ever attempted suicide, how many times, method and at what age(s)?
Are you currently taking medication?*

YesNo
If yes to the above, please list them below:*
Past Therapy Experience
Have you received previous therapy in the past?*

YesNo
Have you been assessed in the past?*

YesNo
If yes to the above, please provide the date of assessment:*

DayMonthYear
Date
Do you think it was helpful?*

YesNo
Please provide details of why it was/wasn't helpful:*
Goals for this service
What are your main concerns/issues?*
How long have you been concerned about this?*
What are your main three goals for this therapy?*
Please list all the previous assessment/therapy services received in the past year:*
Do you give Empowered Therapy & Training permission to contact other health professionals, stakeholders etc in regards to assessment/therapy to ensure open communication and comprehensive assessment?*

YesNo
Please list other health professionals or stakeholders etc which you give EmpoweredTherapy and Training permission to contact:*
If you would like to make a complaint, or provide positive feedback regarding your experience with us, you may go onto our website to fill out our feedback form. Do you understand?*

YesNo
Client/ Participant/Parent/Guardian Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Client Welcome Form Nationwide

Emergency Contact

How did you hear about us?

Prior Life Experience

Past Therapy Experience

Goals for this service