Client Intake & Consent Form

Name *

First NameLast Name

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

What is your age?*

Occupation*

Marital Staus*

Do you have children? If yes, please specify how many and their ages. *

Have you ever been diagnosed with a chronic physical or mental illness? If yes, please provide details. *

Are you taking medication?*

YesNo

If yes, please list your current medication & dosage. If not, just write N/A below.*

Do you provide consent to contact your GP?*

YesNo

If yes, please provide your GP name and clinic address below.*

Please upload any documents you believe may be useful for me to know (medical results, psychological assessments, NDIS Plans, Dr's referrals etc...)

I understand that the theraputic methods and advice used by my therapist is not a substitute for psychiatric treatment. I understand these methods to be theraputic and conditioning process, where you are taught to use your own abilities for your benefit and wellbeing.

1. I have been advised above by my therapist of the scope of therapy and I give my full consent to receiving therapy sessions as outlined during my online booking process for this and in any future session.

2. I understand that my therapist does not prescribe medications for or diagnose any condition.

3. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability.

4. I have accurately provided background information as requested by my therapist.

6. I understand that, I may be referred to another specialist by my therapist if they determine my situation to be outside the scope of their clinical focus.

7. I know my progress is dependent upon my efforts and that there are no guarantees as to the result or progress to be made. I understand that the success of the treatment will be in direct proportion to my commitment to a positive result.

8. I, the undersigned, also understand all questions and verify that all information is complete and accurate to the best of my knowledge. With this understanding, I hereby grant my therapist permission to use the counselling tools they are qualified to use with me or the minor/child whose name appears on this form. I (we) further grant permission for the sessions to be recorded as needed.

Disclosure Statement

CONFIDENTIALITY
I understand that confidentially regarding my sessions will be honored between my therapist and me. This same confidentially is respected when working with minors under the age of eighteen. Matters regarding sessions will be kept confidential except in the following circumstances:

You grant me specific permission to release information to a specific individual or agency;
I have reason to suspect child abuse
I have reason to believe you are an imminent danger to self or others;
In the case of the subpoena of your therapy records.
From time to time, I may feel the need to consult with other colleagues, in this circumstance, clients are not identified by name and confidentiality is maintained at all times.

Your signature below constitutes your permission for such consultations.

Appointments for children under age 18 require written consent from the parent or guardian. For optimum results, it is recommended that parents/guardians are not always there to accompany children during their session.

WHAT YOU CAN EXPECT FROM ME:

Because you have decided to become a client of mine, I owe you some things:

•You can expect me to schedule appointments and live by them.
•You can expect me to focus on you completely to during our session, and to perform with a high level of professionalism.
•You can expect me to be respectful.
•You can expect me to be well trained.
•You can expect me to speak in plain English and not use jargon.
•You can expect me to explain anything you do not understand clearly, and to answer any and all questions with patience and understanding.

During our sessions I facilitate you to access your own internal tools and resources. I also suggest, educate, motivate and inspire you to get well and excell.

By signing this document, I am confirming that I understand all information outlined above. I confirm the information I have shared above is true to the best of my knowledge, and I agree to all the terms listed above.

I understand and consent to the Terms & Conditions as outlined on this online form.*

Yes

Signature*

Client Intake & Consent Form + K10

Medical History

Terms, Conditions & Scope of therapy