Client Intake/Consent Form

Client Intake and Consent Form

As part of providing counselling services, your counsellor will need to collect and record personal information relevant to your current situation. This information is essential for the counselling assessment and therapeutic process. These forms are confidential, and the information you provide will be only used for therapy purposes. Before completing the form, please review the Counselling Agreement below and provide as much detail as possible to ensure the best counselling service.
Personal Details
Name*

First NameLast Name
Gender identity
Pronouns
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First and Last NameRelationship
Emergency Contact Phone Number*
Emergency Contact Email*
example@example.com
Health History
Are you currently taking any prescribed medications? If yes, please list them below:
Have you ever been diagnosed with a mental health condition? If yes, would you feel comfortable sharing the diagnosis?
Have you previously received any type of mental health services such as counselling or psychiatric services? If yes, please provide details:
Counselling Goals
What brings you to counselling at this time and how long have you been experiencing this?
What are you hoping to achieve through counselling/what goals would you like to achieve?
Is there anything else you think is important for your counsellor to know?
Do you have any specific preferences or expectations for your counselling sessions?
Counselling Agreement

Please read carefully information provided below
Confidentiality: Your personal information and anything discussed during your sessions, as well as any counselling notes, are confidential. However, there are excpetions to confidentiality:
- If there is clear and imminent danger of harm to yourself or others, the counsellor is legally required to report this information to the authorities to ensure safety.
- Counsellors must notify the relevant authorities if they learn of, or strongly suspect, physical or sexual abuse or neglect of anyone under 18 years of age.
- A court order issued by a judge may require the release of information from records or require the counsellor to testify in a court hearing.
Service Limitations: PS Counselling Services offers support for common life challenges but does not assess, diagnose, or treat serious mental health disorders.

Sessions: Each session lasts 50 or 90 minutes, and will end at the scheduled time, even if you arrive late. No sessions will be conducted if you are under the influence of substances.

Cancellation Policy: Please provide 24-hour notice for cancellations, otherwise full fee will be charged for late cancellations or missed sessions.

Fees & Payment: Invoices are issued after each session.
Preferred payment is via bank transfer within 7 days.
Bank details:
Commonwealth Bank
Paulina Stanek
BSB 062-692
ACCOUNT 7567 6829
Consent

Please read carefully and sign
- I understand, have read, and agree to this Counselling Agreement with Paulina Stanek of PS Counselling Services (ABN: 11658276091). This agreement constitutes full disclosure and supersedes any previous verbal or written disclosures. I consent to all future counselling sessions.
- I am aware that confidentiality is maintained unless I pose a risk to myself or others, disclose plans to harm others, indicate that vulnerable individuals are in danger, commit or intend to commit a serious crime, or as required by law. I understand that withholding information or providing misinformation may impact my therapy.
- I acknowledge the counsellor’s qualifications and adherence to the Australian Counselling Association’s Code of Ethics and Practice. I understand the limitations of the services provided and that the counsellor does not assess, diagnose, or treat serious mental health disorders.
- I agree to participate actively in sessions, complete assignments, and communicate any changes affecting my therapy. I understand the session durations, cancellation policy, fees, and payment terms. I am aware that I can withdraw from counselling at any time and have the right to complain to the ACA if necessary.
- I release Paulina Stanek from any and all liability associated with counselling services and assume full responsibility for my participation.
Date*

MonthDayYear
Date
Signature*

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Counselling minors

Please provide below information if you are inquiring for counselling for a child under your care
Name of the child:

First NameLast Name
Child's residential address if different from yours:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Briefly describe what brings your child to counselling:
Consent for counselling minors

Please read carefully and sign as a parent or a guardian
- I understand, have read, and agree to this Counselling Agreement with Paulina Stanek of PS Counselling Services (ABN: 11658276091) for the provision of counselling services to my child.
- I consent to my child participating in counselling sessions and acknowledge that confidentiality will be maintained unless there are safety or legal concerns, such as harm to self or others, risks to vulnerable individuals, or other mandatory reporting obligations.
- I agree to provide any relevant information to support my child’s therapy, understand the session structure, cancellation policy, fees, and payment terms.
Date

MonthDayYear
Date
Signature

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Client Intake and Consent Form

Personal Details

Health History

Counselling Goals

Counselling Agreement

Consent

Counselling minors

Consent for counselling minors