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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-
Day
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Month
Year
Date of Birth
Mobile Number
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-
Area Code
Phone Number
Email
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example@example.com
What is your preferred mode of communication? Text/phone/email
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Emergency Contact Full Name
*
Emergency Contact Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Would you like to claim your sessions through private health insurance? If you’re unsure whether your fund covers counselling or psychology, please check with your provider. Then select your fund below so I can apply the correct rebate.
*
Please Select
Not claiming through private health
ahm
Bupa
Defence Health
Doctors Health Fund
Emergency Services Health
Frank Health Insurance
GMHBA
HBF
Healthcare Insurance Ltd
Health Partners
HCF
HIF
Hunter Health Insurance
Latrobe Health Services
MBF
Mildura Health Fund
Mutual Community
Navy Health
NRMA Health
Nurses & Midwives Health
Onemedifund
Peoplecare
Phoenix Health Fund
Police Health
Queensland Country Health
Medibank
see-u by HBF
St Luke’s Health
Teachers Federation Health
Teachers Union Health (TUH)
Territory Health Fund
UniHealth
Westfund
Select your preferred appointment days:
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Monday
Tuesday
Wednesday
Thursday
Friday
(Flexible) - Your earliest availability
Select your preferred appointment times:
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Morning (9:00 AM – 11:00 AM)
Lunch (11:00 AM – 1:00 PM)
Early Afternoon (1:00 PM – 3:00 PM)
Late Afternoon / Early Evening (3:00 PM – 6:00 PM)
(Flexible) - Your earliest availability
Professional Supervision (only complete if applicable) – Organisation Payment Details
If your organisation is paying for supervision, please provide the organisation name, accounts contact, email and phone number.
Referral Source - How did you hear about us?
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Referred by a healthcare professional
Referred by a friend or family member
Word of mouth
Workshop / Event
Social media (Instagram, Facebook, YouTube)
Referred by parish priest
Other
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
Session fees are based on the duration of counselling provided. Any additional time exceeding the allocated session duration may incur an additional fee. Clients will be invoiced following each session, with payment required within the agreed timeframe. Accepted payment methods include available electronic and direct payment options. Clients remain responsible for payment of services provided, regardless of private health insurance rebates or third-party payment arrangements. Outstanding payments may result in the suspension of services until the balance is settled. Repeated late or unpaid accounts may result in termination of services at the discretion of Empowering Minds Therapy. Counselling packages are offered to support continuity of care. Package payments are non-refundable and cannot be exchanged for monetary value. Sessions purchased as part of a package must be used within 12 months of purchase, are non-transferable, and may only be redeemed through future counselling appointments with Empowering Minds Therapy. Unused sessions cannot be converted into cash, credit, refunds, or any other form of reimbursement. Package sessions are subject to appointment availability. By purchasing a counselling package, clients acknowledge and agree to these terms and conditions.
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.
Upload Supporting Documents (Additional Information & Diagnoses) *Not Mandatory
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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.
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Client Signature
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