Counseling Intake Form

Counseling Intake Form
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Date of Birth

MonthDayYear
Date
ID/Passport Number
Email
example@example.com
Employment
Primary Care Provider
Referral Name

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Preferred Method of Contact
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Relationship
Medical History
Please check all the apply

Other
Do you use tobacco?
Do you use alcohol?
Caffeine use?
Have you been convicted of drug related charges?
Please explain the circumstances
Are you currently taking prescription medication?
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone
Format: (000) 000-0000.
Have you had any surgeries in the past 5 years?
Please specify:
Family history

Other
Mental Health History
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Therapist Name

First NameLast Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
Service You Are Seeking

Please select the service you’re looking for, make payment after signing the form and send proof of payment after signing the form.
Type a question
Bank Details:

Gift Moranye

Discovery Bank

10727262787

Transaction Account

Please don't forget to send proof of payment after filling out this form to receive your booking link
Confidentiality & Boundary Agreement
The following guidelines will elaborate what to expect from the counseling
relationship.

Confidentiality in our counseling relationship is an integral part of my practice. By law I am required to keep whatever that is shared in our session private. If you have any questions or concerns about your information, privacy please let me know via email moranyewellnesscounselling@gmail.com

Circumstances that may affect Confidentiality.

1) When the client discloses information that relates to abuse or neglect of/to
a vulnerable adult or a minor.
2) When a client is planning to harm themselves or another person.
3) If as a counsellor there are reasons that the client is a risk to themselves or
might be a risk themselves. If legally the court of law requires information
from the counselor.

DISCLAIMER: IF CIRCUMSTANCES ARISE DURING OUR COUNSELING RELATIONSHIP,
I AS YOUR COUNSELOR WILL MAKE EFFORTS TO DISCUSS AVENUES WITH BEFORE
EXTERNALLY DISCUSSING ANY INFORMATION

Contact me, bookings, working hours, cancellation, late arrival, referrals and
concerns.

Contacting Me:
I can only be contacted via email, or WhatsApp. Please let me know via email
or WhatsApp anything that may be of concern. I am the only one that has
access to this information, and it will always be held privately. You can contact
me Monday – Fridays 9:00 a.m. – 14:00 p.m.

Bookings:
Regarding bookings, I encourage clients to make bookings via a link that'll be sent after payments have been made and this form is signed. The link will be sent again after the client signs the consent form and the link does not need to be renewed.

Counseling is like taking an antibiotic, you
may feel better after the first session or two, but it does not mean that the
infection or problem has disappeared. I encourage you to at least attend 8
sessions and for the best results 12 sessions.
Cancellation:
Please kindly provide me with a minimum of 24 hours’ notice if you want to
change or reschedule an appointment. I understand unexpected events can
occur, and this is something you may inform me about. However, when we
schedule a session, I reserve that time exclusively for you.

Late Arrival:
If you arrive late, please understand that I am unable to extend your session
time. I will wait up to 15 minutes into online sessions before cancelling the session. If I have not been notified, and I will allow a grace period for the cancellation of a session twice before I terminate our process entirely.

All payments are finalized and non refundable when the client arrives late or the client cancells their session an before the session. For cancelled sessions a repayment is not needed rather a re-booking will be made based on previous payments.

Referrals And Concerns:
If you arrive late, please understand that I am unable to extend your session
time. I will wait up to 15 minutes into online sessions before cancelling the session if I have not been notified, and I will allow a grace period for the cancellation of a session twice before I terminate our process entirely.
Contractual Agreement
Please Sign The Agreement Below:
I First Name Last Name ; understand and acknowledge that the person I am about to see is a registered Wellness Counsellor with the ASCHP (WC24/6082).

I have read the confidentiality and boundaries agreement form stipulated above and asked questions about any concerns I may have.

By signing this document, I a) Accept the terms of this agreement, b) Authorize Gift
Zoe Moranye to provide me/ us/ my child with counseling services, and c)
Acknowledge that I must provide a 24-hour notice to cancel or reschedule
session.
Signature Date
Date

MonthDayYear
Date
Signature
Should be Empty:

Counseling Intake Form

Emergency Contact Information

Medical History

Mental Health History

Service You Are Seeking

Confidentiality & Boundary Agreement

Contractual Agreement