CONFIDENTIAL CLIENT INTAKE FORM
Thank you for reaching out for support. The information below helps us understand your needs and how best to work together. All information shared is confidential, in line with ethical and legal guidelines.
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Day
-
Month
Year
Date
Marital Status
Please Select
Single
Married
Divorced
Widowed
Email
example@example.com
Preferred Method of Contact
E-mail
Mobile
SMS
How Did You Hear About Us
Search Engine
Your Website
Social Media (Instagram, Facebook, TikTok, etc.)
Word of Mouth / Friend or Family
Doctor / Health Professional Referral
NDIS Referral / Support Coordinator
Other (please specify)
Emergency Contact Details
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Format: (0000) 000-000.
Relationship
REGULAR DOCTOR (GP)
First Name
Last Name
Landline Number
Format: (00) 0000-0000.
Mobile Number
Format: (0000) 000-000.
REFERS NAME
First Name
Last Name
Landline Number
Format: (00) 0000-0000.
Mobile Number
Format: (0000) 000-000.
Email
example@example.com
NDIS
Please note that NDIS is only available to those NDIS clients that are self managed or plan managed as Equine Resolutions is not an NDIS registered service provider. Services Offer will come under CAPACITY BUILDING - 15_043_0128_1_3
Do You Have an NDIS Plan
Yes
No
If Yes, please provide your plan number
What Type of Plan Do You Have
Plan Managed
Self Managed
MEDICAL HISTORY
Do you have any current mental health diagnoses?
Yes
No
If Yes, please give details
Are you currently taking an medications (including supplements)
Yes
No
If Yes, please give details
Do you have any physical health issues or disabilities that may affect your well-being or therapy experience?*
Yes
No
If Yes, please give details
Do any of the following apply to you:
Allergies
Anemia
Angina
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Cancer
Crohn's Disease
Depression
Diabetes
Gallbladder Disease
GERD (Reflux)
Hypertension
Irritable Bowel Disease
Migraine Headaches
Myocardial Infarction
Seizure Disorder
Thyroid Disease
Other
Other:
Do you Vape or Use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Have you been convicted of drug related charges?
Yes
No
Please explain the circumstances
PRESENTING CONCERNS
What are you hoping to get out of therapy:
Please briefly describe the main reason(s) you are seeking therapy:
What have you already tried to address these concerns:
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Therapist Name
First Name
Last Name
Stress / Anxiety Levels (1-10):
On a scale of 1 - 10 what do you consider your daily stress levels to be ? 1 being very little and 10 out of control
Sleep:
Please provide a snapshot of your sleeping patterns
Past Trauma or Significant Events
Your welcome to share as much or as little as you feel comfortable, please provide a snapshot of your sleeping patterns
Safety (are you currently feeling safe in your daily life?)
Yes
No
If feeling unsafe, would you like to discuss this during you session
Have you had thoughts of self-harm or suicide recently or in the past?
Yes
No
If yes, would you like to discuss this during your session?
Additional comments or concerns
FEES & CANCELLATION
Session fees are charged in line with the current NDIS Price Guide or private rates as agreed in your Service Agreement. Payment is required on the day of service, or via your plan manager if applicable. We kindly ask for at least 24 hours notice if you need to cancel or reschedule your appointment. Cancellations made with less than 24 hours’ notice, or non-attendance, will be charged at the full session fee
LOCATION
In person sessions will be conducted at Gold Coast Equestrian Centre, 212 Stewart Rd, Clagiraba QLD 4211
CONSENT & CONFIDENTIALITY
I understand that what I share in therapy is confidential,with the exception of risk of harm to self and/or others, legal requirements, or with my written consent.*I give permission for my therapist to liaise with other professionals if needed with my consent*I understand I can withdraw from therapy at any time.*
Date
-
Day
-
Month
Year
Date
*Your signature below indicates that the information you have provided above is truthful.
Signature
Submit
Submit
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