EVIDENCE-BASED PRACTICE. CLIENT-CANTERED PROGRESS
MERIDIAN WELLNESS SOLUTIONS
Registration No (CIPC): 2021/777546/07
SACSSP Reg No: 1033525 | BHF Practice No: 0966304
Email:
meridianwellnessSA@yahoo.com
Consultation Request Form
Welcome
Thank you for your interest in Meridian Wellness Solutions.
This form is intended to help us understand your needs and determine how we can best assist you. Completing this form is a request for a consultation and does not guarantee an appointment. Once your request has been reviewed, a member of our administration team will contact you to discuss the next steps.
All information provided will be treated confidentially and managed in accordance with applicable privacy and professional standards.
Section 1: Personal Information
Full Name and Surname
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Identity/Passport Number (Optional)
Preferred Pronouns (Optional)
Section 2: Contact Information
Cell Phone Number
Format: (000) 000-0000.
Alternative Contact Number (Optional)
Format: (000) 000-0000.
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EVIDENCE-BASED PRACTICE. CLIENT-CANTERED PROGRESS
Email Address
Preferred Method of Contact
Preferred Method of Contact
Telephone
Email
WhatsApp
Section 3: Consultation Information
Who is the consultation for?
Who is the consultation for?
Myself
My Child
My Partner and Me
My Family
Someone under my care
Other
Which service are you seeking?
Which service are you seeking?
Individual Counselling
Couples Counselling
Family Counselling
Parenting Plan
Child Custody Consultation
Guardianship Services
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EVIDENCE-BASED PRACTICE. CLIENT-CANTERED PROGRESS
Family Preservation Services
Family Group Conference
Psychosocial Assessment
Professional Report
Organisational Wellness Services
Unsure - I would like guidance
Section 4: Brief Reason for Contact
Please briefly describe the reason for your consultation request and what you hope we can assist you with.
Section 5: Appointment Preferences
Preferred days
Preferred days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred time
Preferred time
Morning
Afternoon
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EVIDENCE-BASED PRACTICE. CLIENT-CANTERED PROGRESS
No Preference
Section 6: Payment Information
How do you intend to pay for your consultation?
Cash / EFT
Medical Aid
Not yet sure
If Medical Aid, please indicate the scheme (if known):
Section 7: Referral Information
How did you hear about Meridian Wellness Solutions?
Psychology Today
Facebook
Google Search
Friend or Family
Healthcare Professional
Employer
School
Other
Declaration
I confirm that the information I have provided is true and accurate to the best of my knowledge.
I understand that:
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EVIDENCE-BASED PRACTICE. CLIENT-CANTERED PROGRESS
This form is a request for a consultation and does not guarantee an appointment.
Meridian Wellness Solutions is not a 24-hour emergency or crisis service.
Should my consultation be confirmed, I may be required to complete additional intake and consent documentation before my appointment.
Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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