Client Intake Form

Client Intake Form

Safe & Sound Counselling
Full Name*

First NameLast Name
Pronouns.
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
Occupation
Occupation*
Employer*
Phone Number
Please enter a valid phone number.
Emergency Contact Details
Emergency Contact Name *
Emergency Contact Phone Number*
Emergency Contact's Relationship to client*
Medical Information
GP*
GP Contact details*
Psychiatrist (if any)
Psychiatrist Contact Details

Medical Information
Have you been treated for any health conditions in the last year?

YesNo
Any major illnesses or hospitalisations?
Please advise of any past or present alcohol and recreational drug use (please note there is no judgment surrounding this).
Do you have any other health problems, no matter how insignificant they may seem?
Are you taking any prescription medication for psychological or physical health conditions? If yes, please specify what kind and reason.

Stress and Anxiety/Upsetting Events
Please comment on the most current significant source(s) of Stress/Anxiety.
Have you gone through any upsetting events recently or in the past that have been taking up a lot of your attention as of late? ? (Please specify)
How do you reduce or manage your stress?

Safety Considerations:

Self Harm/Meltdowns/Suicidal Ideation
At times everyone feels down or upset. However, when someone feels very low, they may think about harming themselves or suicide.

If the answers to any of the below is 'yes' kindly book in for 90 minutes if possible so we have time to do a risk assessment and/or a safety plan without compromising on understanding the mechanisms behind this. I assure you a Safety Plan is a gentle process and nothing to be concerned about. I will basically provide you with coping strategies and ideas on what you can do if in crisis.
Do you self harm?(Cutting, hitting head against wall, violence towards self etc)*
Do you have suicidal thoughts? If so, please elaborate.*
If you answered “yes” to the question above,have you considered how you might act on these thoughts or when? In other words, did you have a plan and means to carry them out? Please explain.*
Coping Mechanisms: What has helped you through difficult times in the past?*
How do you take care of yourself?
Who do you turn to for support?*

Strengths and Resources: What are some of your strengths, hobbies, interests?
What are your goals or, what would you like to achieve out of our sessions together? (You can simply answer you would just like to talk if you are unsure)*
Previous Support: Is this your first time seeking support? If not, please elaborate on what has been helpful/unhelpful in the past.
Additional Information: Is there anything you would like to add so I can provide you with the best support possible?
What is your general availability? If it changes that is completely fine.My working hours are 11am-pm Mondays-Wednesdays.*

Mondays daytimeMondays eveningTuesdays daytimeTuesdays eveningWednesdays daytimeWednesdays eveningIt variesOther
What is your desired frequency. It is generally recommended that we start by meeting weekly with at least the first session being 90 minutes. Some need more some need less.
Weekly, fortnightly etc
May I ask how you found me? (eg Google,Instagram, referral etc)

Agreement and Acknowledgement
Confidentiality Statement
All information shared on this form will be held in strict confidence, subject to legal requirements. Safe & Sound Counselling adheres to the Privacy Act 1988 and the Australian Privacy Principles (APPs) to protect your personal and sensitive information. This information is used solely to provide you with the best possible care and support. Information will not be shared with any third parties without your express consent, unless there is a serious threat to life or health, or as required by law.

Final Acknowledgment and Signature

By signing below, I acknowledge that:
- Accuracy of Information: I have provided accurate and current information in this Intake Form.
- Confidentiality and Privacy: I understand the confidentiality provisions outlined in this form, including Safe & Sound Counselling’s adherence to the Privacy Act 1988 and Australian Privacy Principles (APPs), ensuring my information is kept confidential and used solely for providing care and support, unless otherwise required by law.
Terms and Conditions Compliance:
- I confirm that I have reviewed and agree to the Terms and Conditions/Cancellation., Reschedule and Payment Policy, which include policies on booking, cancellations, refunds, and billing for non-face-to-face services.
- I understand that payment is required at the time of booking to confirm my session, and no refunds are provided as per the policy.
- For NDIS participants: I acknowledge that I am responsible for ensuring adequate funding is available in my NDIS plan for all applicable services, including non-face-to-face activities, short-notice cancellations, and report writing, with approximately 4 hours of funding set aside for any required reports.
Client Signature and Date

By signing below, I confirm my understanding and agreement to the above statements.
Client Signature

Powered by Jotform SignClear
Client Name

First NameLast Name
Date

MonthDayYear
Date
Guardian/Carer/Bill payer Signature (if relevant)

Powered by Jotform SignClear
Guardian/Carer/Bill payer Name (if relevant)

First NameLast Name
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Should be Empty:

Client Intake Form

Occupation

Emergency Contact Details

Medical Information

Personal History

Client's Mental Health History

Family Mental Health

Medical Information

Stress and Anxiety/Upsetting Events

Safety Considerations:

NDIS Participants Only

NDIS Session Booking and Reimbursement Process

Agreement and Acknowledgement

Client Signature and Date