New Client Intake Form
Empowering Minds Therapy
Client Name
First Name
Last Name
Parent/Guardian Name (if client is under age 18)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal Code
D.O.B (or D.O.B of child/adolescent you would like to book in)
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Month
-
Day
Year
Date of Birth
Mobile Number
Best Contact Number
Email
example@example.com
What is your preferred mode of communication? Text/phone/email
Emergency Contact Full Name
Emergency Contact Phone Number
Please enter a valid phone number.
SERVICE AGREEMENT
Clients are expected to actively participate in the counselling process to gain the most benefit. As part of this process, discussing previous counselling experiences may help identify effective approaches.
PAYMENT TERMS
Sessions are available for 60 minutes at a rate of $140 or 90 minutes at a rate of $200. Any time exceeding the allocated session duration will incur an additional fee. Clients will be invoiced directly after each session, with payment due within 24 hours. Accepted payment methods include cash, direct debit, credit card, and PayPal’s four-payment split option to ease financial burden. Failure to make payment within the required time frame may result in a suspension of services until the outstanding balance is settled. Repeated late payments may lead to termination of services at the discretion of Empowering Minds Therapy.
LATE ARRIVAL AND CHANGE OF SCHEDULE
Fees are based on the scheduled session time. No adjustments will be made for client being late or early termination. If the therapist is late, the lost time will be compensated by extending the session as agreed. The therapist will wait 15 minutes before considering the session cancelled without notice. Cancellations require 48 hours' notice (*except in emergencies); otherwise, the full fee applies. If the therapist cannot provide a session due to unforeseen circumstances, an alternative time will be offered.
CANCELLATIONS
A minimum of 24 hours’ notice is required to cancel or reschedule a session (*except in emergencies). Cancellations made with less than 24 hours' notice will incur the full session fee. If Empowering Minds Therapy is unable to provide a scheduled session due to extenuating circumstances, we will notify you as soon as possible and offer an alternative appointment time.
INFORMATION - DUTY OF CARE
Empowering Minds Therapy upholds your right to confidential counselling services. However, confidentiality may be breached if your counsellor determines that there is a risk of harm to yourself or others, in accordance with legal and ethical obligations. All personal information, including session notes, will be securely stored in a password-protected electronic system. Records of your sessions will remain confidential unless disclosure is legally required, such as when requested by a court of law. Referrals to another service will only occur with your knowledge and consent, ensuring that your confidentiality is maintained. If your case escalates into a high-risk category, the counsellor reserves the right to recommend a more appropriate service. Such cases may fall outside the scope of practice of Empowering Minds Therapy and may require referral to a specialised organisation better equipped to meet your needs and ensure your safety and well-being.
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Agreement of Terms
I have read and understood the above Consent Form. I agree to these conditions for the counselling services provided by Empowering Minds Therapy.
Date
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Month
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Day
Year
Client Signature
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