Client Intake Form

Date Completed

Date

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Please enter a valid phone number.

Home Phone Number

Please enter a valid phone number.

Email

example@example.com

Gender

Age

Birth Date

Date

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

What is you relationship status?

Occupation

Employed by

Religious affiliation

If applicable

How did you hear about Samway Counselling Services?

Briefly describe your general health

Are you currently taking any medication?

YesNo

If 'YES', what medication are you taking and for what?

Are you currently using alcohol and/or drugs?

YesNo

If 'YES', which and how frequently?

Have you previously had counselling or any type of mental health service?

YesNo

If 'YES', what for?

How did you feel about that experience?

What is the main issue that brings you to counselling?

How long has the current issue been presenting itself?

What do you hope for / expect from counselling?

Is there any other information you would like your counsellor to know?

How would you rate your general happiness and well-being?

I often experience;

I often have;

I often feel;

By submitting this form, I declare that the information on this form is correct. I acknowledge that I have read and understood the terms and conditions contained in this Client Intake Form.*

I agree

Signature*

Use your mouse or finger to sign in block. It's OK if it does not resemble your usual 'ink' signature

Terms & Conditions

I understand that my counsellor will help me to understand myself, help me clarify my problems, goals and objectives, and help me look at alternative solutions to my problems. This will involve homework, which I am prepared to commit myself to, as requested. I further understand that that my Counsellor’s role is primarily that of facilitator and that he/she will collaborate with me as I make decisions regarding my own well-being. I am fully responsible for the decisions I make about my life and behaviour.

I understand that the model of counselling used looks at the past and the present. It includes the exploring and resolving of past hurts, my family of origin, feelings, thought patterns and communication skills, all having in view personal restoration to wholeness. It is designed to help me focus on achieving optimum health, and encouraging me to seek and find an enriching and fulfilling life.

I understand that I am personally responsible to pay the current counselling fees applicable to my type of session, as advertised on Samway's website.

The relevant payment is to be made at the time of booking. I also understand that arrangements with insurance companies, employers and the like for reimbursement of fees, is my responsibility.

I understand that 24-hour cancellation notice is required, failing which I will forfeit my session fee.

Terms of Service

As part of providing a counselling service to you, Samway Counselling Services will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the assessment and intervention that is conducted.You may access the material recorded in your file upon request, subject to the exception in National Privacy Act 1988.

Confidentiality

All personal information gathered by the counsellor during the provision of the counselling service will remain confidential and secure except when:

1. It is subpoenaed by a court, or

2. Failure to disclose the information would place you and/or another person at risk; or

3. Your prior approval has been obtained to

Provide a written report to another professional or agency e.g. a GP or a lawyer; or
Discuss the material with another person e.g. a parent or employer.

4. Abuse of children is a mandatory reporting offence which your counsellor is required by law to report.

Electronic Information

It is not possible to guarantee the protection of information that is transferred or stored electronically. Therefore, the Client waives any action legal or otherwise against Samway Counselling Services and holds Samway Counselling Services harmless for any interception of Client information resulting from the use of electronic information.

Fees and Payments

Session fees are charged as per the rates listed on our website. Payment is made prior to appointment as per payment methods listed on our website. Failure to show for an appointment, or give at least 24 hours’ notice of cancelling, may incur a forfeiture of the session fee. Appointment length is 55 minutes (individual) and 75 minutes (couple).

Client Intake Form

Emergency Contact Details

Relationship

Medical Information

To Help Us Help You

Symptoms

Agreement