Counselling Intake & Consent Form
Client Full Names
*
First Name
Last Name
Client Partner Name (Only for Couple Counselling)
First Name
Last Name
Email
*
example@example.com
Cell Phone
*
-
+27
Phone Number
Marital Status
*
Single
Married
Never Married
Divorced
Widowed
Client ID number
*
13 digit ID number of client attending session
Place of Employment or Current High School if a learner
*
Address
*
Your residential address
Suburb
City
State / Province
Postal Code
Method of payment
*
Private Cash
Medical Aid
Select one from drop down list
Medical Aid name
Please note: Client is responsible for payment of fees should the medical aid decline. Client to enquire from medical aid regarding fund availability
Main member Full Name and Surname
Medical Aid Main member ID number
13 digit ID number required for both Private and medical aid patients
Medical Aid number
Please add all the information
Medical Aid plan type
Please add all the information
Medical Aid dependency code
Please add all the information
Contact information
*
First Name
Last Name
Emergency/Second Contact Information
Incase of emergency or if we are unable to reach you.
Phone Number
*
-
+27
Phone Number
Individual Counselling Screening. Mental Wellbeing
For Counselling clients only
Have you thought about committing suicide
Yes
No
Other
Have you attempted committing suicide
Yes
No
Other
Are you currently taking prescription medication?
Yes
No
Have you seen a Counsellor, Psychologist, Psychiatrist or other mental health professional before?
Yes
No
Have you been diagnosed by a Psychologist, Psychiatrist or GP before?
Yes
No
Do you have any pending court cases?
How did you hear about this practice
*
Social media
Employee Wellness Services
Doctor
Referral
Psychiatrist
Other
Date
-
Day
-
Month
Year
Date
Booking confirmation
*
I agree to the Cancellation fees - *I understand that I am liable for payment where medical aid claims are rejected and that it will be settled in cash /EFT within 48hrs and failingwhich the account will be handed over to a debt collection. * I understand that I have to notify the Psychologist no later than 48hrs before the session if I am unable to attend for any unavoidable situation Or on Friday if the session is on a Monday. *Cash payments to be made prior to session or on the day by arrangement. *Please click on link below for T&C
*
https://www.newleafcounselling.co.za/terms-and-conditions
The information provided is true and correct.
*
I agree
Additional comments or concerns
Signature
*
Submit
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