Cal Spiers Counselling New Client Intake Form

New Client Intake Information and Consent Form
Cal Email
example@example.com
Welcome to Caroline Spiers Counselling

This form provides information about the practice and policies and helps me determine whether I am the most appropriate therapist for your needs. Please complete all sections and I am happy to discuss this form prior to our first session.
- Name
  
  First NameLast Name
- Preferred Pronouns
- Email
  example@example.com
- Phone
  Please enter a valid phone number.Format: 0000 000 000.
- Date of Birth
  
  DayMonthYear
  Date
- Client Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- These questions are optional and are asked to help provide culturally safe and affirming care.
- Do you identify as:
- Do you identify as LGBTQIA+?
- If yes, is there anything you would like me to know that will help provide you with safety and support for our sessions?
- Emergency Contact Name
- Relationship
- Phone Number
- Email
- Medical/health professionals (psychologist, psychiatrist, social worker, support worker etc.)
- Medication (if you would like to share)
- What brings you to counselling?
- What are you hoping to achieve through therapy?
- Have you previously attended psychotherapy sessions?
- Please briefly describe what type (eg. EMDR/ACT) and how long you attended
- Are you currently experiencing thoughts of suicide or self-harm?
- Please briefly describe how recently, and if you have a plan in place
- Do you currently have any concerns about your immediate safety?
- Please describe
- Session Locations
  
  Counselling sessions are provided online, via video or phone call or in person.
  
  In person sessions are available at
  
  • 8/10 Clinch Avenue Preston, Victoria
  • 6/160 Edward Street Brunswick, Victoria
  
  Please say if you are able to attend one or both venues easily. Both are ground floor, space for a wheelchair/mobility aid and Preston has an accessible toilet.
  
  Parking is available next door 90 minutes free Woolworths car park or in the street opposite the building entrance 2 hours free
- Attending Sessions
  
  To ensure privacy, safety and therapeutic effectiveness:
  - Sessions take place between you and the Counsellor Caroline Spiers
  - If you arrive unable to participate safely due to intoxication or another reason as determined by the Counsellor, the session may be cancelled and the cancellation policy may apply.
  - If a session has been agreed to occur via phone or video call, you must be in a private, confidential location. If you are driving, or in a public place (such as a café), where others may hear you or otherwise unable to participate privately and safely, the session will be ended and rescheduled.
- Cancellation Policy
  
  Where possible, provide at least 24 hours notice if you need to cancel or reschedule.
  
  Appointments cancelled with less than 24 hours' notice, or missed without notice, will incur 100% of the session fee, except in exceptional circumstances at Counsellor's discretion.
- Fees & Invoicing
  
  Invoices and payment administration is managed by Jacob @ Bear Bookkeeping Solutions
  
  By attending therapy sessions with the Counsellor you consent to your contact details and invoice information being shared with Bear Bookkeeping solely for the purpose of managing appointments, invoicing and payments.
  
  Fees 2026 are:
  
  $200 per hour session individual sessions
  
  $300 per hour session couples sessions
  
  I operate a sliding scale of fees for those experiencing challenges with finances
- Confidentiality
  
  Your privacy is protected.
  
  Everything discussed during counselling is confidential except where disclosure is required or permitted by law or where there is a serious and imminent risk of harm.
  
  Confidentiality may be breached if:
  - The Counsellor reasonably believes there is an imminent and serious risk that you may cause significant harm to yourself or another person within 2 hours of a session ending
  - disclosure is required by law (for example, mandatory reporting obligations or a court order); or
  - you provide written consent (email) for information to be shared.
  Where it is safe and practical to do so, I will discuss any proposed disclosure with you before contacting emergency services or another appropriate person.
- Signature
- Signed By
- Signed Date
  
  DayMonthYear
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New Client Intake Information and Consent Form

Welcome to Caroline Spiers Counselling

Session Locations

Attending Sessions

Cancellation Policy

Fees & Invoicing

Confidentiality