Intake Form
Who is seeking counseling and psychotherapy?
Myself
My Child
Other
Personal Information of Counseling Person
Name of person attand to counselling & psychotherapy
*
First Name
Last Name
Name of the person who fill out the form
*
First Name
Last Name
Date of Birth person attends counselling
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
School Name (If Applicable)
School Year (If Applicable)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address of person attend to counseling and psychoterapy.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Your Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is your address same with the counseling person?
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship with the counseling person.
Parent
Grandparent
Carer
Friend
Other
Back
Next
Referral Information
How did you hear about us?
*
General Practitioner
Specialist
Family or friend
Social Media
Internet Search
Other
Referrer Name ( if its professional GP)
First Name
Last Name
Referral Date
-
Month
-
Day
Year
Date
Counseling
Reason for counselling & psychotherapy
*
Abuse
Addiction
Adjustment
Ageing Concerns
Anger
Anxiety
Depression
Displacement
Eating Disorders
Family
Financial Problems
Grief & Loss
Identity
Learning Difficulties
Loneliness
Obsessive Compulsive
Panic Attacks
Parenting
Post-Traumatic Stress
Relationship
Self-Esteem
Self-Harm
Sexual Issues
Sleeping
Smoking
Stress
Suicidal Thoughts
Trauma
Weight Concerns
Work Stress
Other
Please specify any previous counseling experiences
e.g. Mental Health Treatment Plan [MHTP], Employee Assistance Program [EAP], Private
Please specify any medical/allied health services who have been/are involved
Permission is given for the counsellor and psychoterapist to obtain and exchange appropriate written or verbal information with the following persons/agencies
Please specify any diagnoses
Please specify all medications
Please specify any other concerns
Counselling Agreement
Introduction This agreement outlines the terms and conditions of the therapeutic relationship between the client and Hibernium Therapy (HT). By signing this document, the client acknowledges their understanding and acceptance of the terms related to therapy services, including both face-to-face and online therapy. This agreement also includes the client’s consent for the processing of personal data in compliance with GDPR, and consent to share personal details with necessary authorities or professionals when required by law or to ensure appropriate care. Nature of Services I, [Client's Full Name], hereby consent to engage in therapy services provided by Hibernium Therapy. These services may include, but are not limited to: Individual therapy Couple therapy Family therapy Other forms of counselling as deemed appropriate by the therapist based on the client's specific needs. Therapeutic Approaches Hibernium Therapy employs an integrative approach combining various therapeutic modalities, including but not limited to: Humanistic and Existential Approaches: Focus on self-awareness, personal growth, meaning, and the human experience. Cognitive Behavioral Therapy (CBT): A practical approach that focuses on identifying and changing negative patterns of thinking and behavior. Dialectical Behavior Therapy (DBT): A form of cognitive therapy that emphasizes mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. Online Therapy (HT) Hibernium Therapy offers the flexibility of online therapy, allowing clients to access services remotely through video calls, phone calls, or secure messaging platforms. By agreeing to participate in online therapy, you acknowledge the following: Technology Requirements: You are responsible for ensuring access to a reliable internet connection and a private, secure location for each session. Platform Security: Sessions will be conducted via a secure, encrypted video conferencing platform. While every effort is made to maintain security, there are inherent risks with any online technology. Confidentiality: Confidentiality remains as important in online therapy as it does in face-to-face sessions. You must ensure that your environment is private, and no one else can overhear the session. Limitations: Online therapy may have limitations, such as technical disruptions or reduced ability to read non-verbal cues. It is not suited for emergencies, and you are encouraged to seek immediate help through emergency services when needed. Consent to the Processing and Sharing of Personal Data (GDPR) In accordance with the General Data Protection Regulation (GDPR), I understand that Hibernium Therapy (HT) will process my personal data in order to provide therapy services. This data includes, but is not limited to: Health information pertinent to therapy Hibernium Therapy ensures that all personal data will be handled with strict confidentiality and used solely for therapeutic purposes. The data will not be shared with third parties unless: Required by law: In cases of imminent harm, legal orders, or reporting of abuse, I consent to the sharing of my personal information with necessary authorities (such as emergency services or child protection agencies). Necessary for my care: I consent to Hibernium Therapy sharing my personal data with other relevant professionals (e.g., medical or mental health professionals) when necessary to coordinate appropriate care or treatment. I understand my rights under GDPR, which include the right to access, correct, or request deletion of my personal data at any time by contacting Hibernium Therapy. Confidentiality and Its Limits All information shared in therapy, whether in person or online, is kept confidential and will not be disclosed to anyone without your written consent, except in the following cases: Risk of Harm: If there is a risk of harm to you or others, I may need to take appropriate steps, which may include contacting emergency services. Abuse or Neglect: If I become aware of abuse or neglect involving children, elderly persons, or vulnerable adults, I am legally obligated to report this to the relevant authorities. Court Orders: If ordered by a court of law, I may be required to disclose certain information. Supervision: I may discuss cases with a supervisor for professional development. However, identifying information will be removed to protect confidentiality. Consent to Share Information: I consent to Hibernium Therapy sharing my information with other professionals as necessary for coordinating my care. Fees and Payment Hibernium Therapy offers a range of therapy options with the following fee structure: Initial Appointment: Free of charge (30 minutes) Student Counselling: €40 per session (45 minutes) Individual Counselling: €70 per session (50 minutes) Couple Therapy: €120 per session (90 minutes) Payment Methods: Payment is due at the time of the session and can be made through [insert payment methods: bank transfer, credit card, PayPal, etc.]. Insurance: If you are using insurance to cover therapy costs, please note that some of your information may need to be shared with the insurance provider for billing purposes. You are responsible for any fees not covered by your insurance. Cancellations: If you need to cancel or reschedule a session, please provide at least 24 hours' notice. Cancellations made less than 24 hours in advance may incur the full session fee unless it is due to an emergency or a technical issue with online therapy. Booking Appointments You can book appointments via our website, www.hiberniumtherapy.com, or directly into calendar https://calendar.google.com/calendar/u/0/appointments/AcZssZ3-Ou-LqNAjDSaXMENKRC-Hx5l8GY27ntjiblY= Or by contacting us directly at: Mobile: +353 899 55 1003 Email: hiberniumtherapy@gmail.com Emergency Protocol Hibernium Therapy is not equipped to handle emergencies. If you are in crisis or require urgent assistance, please contact your local emergency services or visit the nearest hospital. You may also contact national or local mental health hotlines for immediate support. Termination of Therapy You have the right to terminate therapy at any time. It is recommended that this be discussed with your therapist beforehand so that a proper conclusion to the therapeutic relationship can be planned. Similarly, the therapist may suggest termination if it is believed that another form of treatment may be more suitable for you, or if there is a significant breach of this agreement. Rights and Responsibilities Client Rights: You have the right to confidentiality and professional, respectful treatment. You have the right to ask questions or express concerns about the therapy process at any time. You have the right to terminate therapy at any time. Therapist Responsibilities: I will provide a safe, supportive, and professional environment for you. I will maintain confidentiality as outlined in this agreement. I will work collaboratively with you to set and achieve your therapy goals. Client Information Consent to Treatment I have read and understood the terms of this agreement, including the nature of services, confidentiality policies, online therapy protocols, my rights regarding the processing and sharing of my personal data (GDPR), and the sharing of my information with necessary authorities or professionals when required. I consent to participate in therapy services provided by Hibernium Therapy
Date
-
Month
-
Day
Year
Date
Back
Next
Signature
Submit
Should be Empty: