The Counselling Wollongong Studio

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Counselling requested* This field is required.THE COUNSELLING WOLLONGONG STUDIO — CLIENT INTAKE This form helps your counsellor prepare for your first appointment. Please provide information about yourself and your children, including children who will not attend, to understand family context and relevant care and safety considerations. Listing a child does not enrol them or consent to treatment. Each participating adult should complete their own intake and consent. You need not describe traumatic experiences in detail; indicate if you prefer to discuss a question privately. Completion does not confirm an appointment or suitability. Family therapy is for participants aged 11 and over, subject to assessment and consent. Younger children may be listed for family context. This form is not an emergency service. If there is immediate danger, call 000. COLLECTION INFORMATION RCS-Health trading as The Counselling Wollongong Studio, ABN 61 529 395 719, collects information for suitability, counselling, appointments, payments, records and relevant legal/professional responsibilities. Information relevant to each function is processed; some providers/subprocessors may process overseas. Missing necessary information may delay assessment or safe care; ask to discuss unknown or sensitive details. You may request access/correction and raise privacy concerns. The counselling agreement separately explains confidentiality and the current mandatory NovoNote arrangement. Intake is not AI or treatment consent.

Individual

Couples

Family

Discuss suitability

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I am completing this form as* This field is required.

Adult seeking counselling

Parent or carer for a proposed child participant

Young person seeking support

Authorised representative

Victims Services Counselling Participant

Other or unsure

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Your full name* This field is required.Enter your own name. Each participating adult should provide their own intake.

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Your date of birth (DD/MM/YYYY)* This field is required.If you are only a representative, leave blank. If unknown or you need to discuss this privately, say so.

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Your address* This field is required.Street, suburb, state and postcode; country if relevant. If recording your address may create a safety concern, enter “Discuss privately” instead. Do not enter an unsafe address.

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Preferred Contact Method* This field is required.Choose the safest primary method. You can describe additional safe methods and restrictions below. No method is selected by default.

Email

SMS

Phone call

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Phone Number* This field is required.

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Email Address* This field is required.

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May we leave a voicemail?* This field is required.

Yes

No

Not applicable or discuss first

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Safe contact times and precautionsOptional: other safe methods, safe times, wording precautions or restrictions. If no method is safe, do not enter unsafe contact details; arrange a safe method with your counsellor through a method already available to you.

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Access, communication and cultural preferencesOptional: interpreter or support needs, accessibility, cultural or identity considerations you would like respected. No diagnosis or cultural disclosure is required.

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Do you have any children?* This field is required.For individual, couples and family counselling, include children whether or not they will attend. Details help us understand family context and relevant care and safety considerations. Listing a child does not enrol them in counselling.

Yes

No

I need to discuss this privately

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Child 1 — full name* This field is required.Include children who will not attend. If unknown or unsafe to record online, enter “Unknown” or “Discuss privately”. If you have no children, leave child questions blank.

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Child 1 — date of birth (DD/MM/YYYY)* This field is required.If unknown or unsafe to record online, enter “Unknown” or “Discuss privately”; do not guess a date.

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Child 1 — address* This field is required.Street, suburb, state and postcode. You may explicitly write “Same as my address above” if correct, or “Provide privately for safety”. No address is copied by default. Include another relevant care address only if safe, or ask to discuss it. Providing an address does not authorise sharing it with another parent or participant.

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Child 1 — your relationshipFor example: parent, step-parent, guardian, kinship/foster carer or another relationship.

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Will or might Child 1 attend counselling?Listing a child for family context does not enrol them or consent to treatment. Family therapy is for participants aged 11 and over, subject to suitability; younger children may still be listed here.

Yes

No

Unsure

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Additional children — include every child, attending or not* This field is required.If there are no additional children, write “None”. Otherwise, for EACH additional child start a new paragraph and give: full name; preferred name (optional); DOB (DD/MM/YYYY); address (street/suburb/state/postcode, explicit “same as my address” if correct, or “provide privately for safety”); your relationship; whether attending (yes/no/unsure); relevant safety/parenting/contact restrictions. Listing a child does not enrol them in counselling.

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Other adults who may attendOptional: names only if appropriate to share; indicate yes/no/unsure about attendance. Each adult needs their own intake and consent. Do not provide another adult’s private history.

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Is there a safe emergency contact?A nominated person is not authorised to receive all counselling information.

Yes

Discuss with counsellor

No safe person

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Emergency contact details and restrictionsIf there is a safe contact: name, relationship and phone, plus any safety or contact restrictions. Otherwise leave blank or write “Discuss”. Do not list an unsafe person.

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What brings you to counselling?Briefly describe the main concerns. You may write “Discuss in session”; there is no need to describe traumatic experiences in detail.

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What would you like help to work towards?Optional goals or hopes for counselling.

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Relevant health or counselling informationOptional: brief relevant health, medication or previous counselling information that would help safe care. You may discuss this in session.

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Occupation or studyOptional, if relevant to your counselling.

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How did you hear about the practice?Optional. This does not affect access to counselling.

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Anything else you would like your counsellor to know?Optional. You can ask to discuss sensitive matters privately.

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Fees and appointments* This field is required.All sessions are 50 minutes. Before 5 pm: individual $140, couples $155, family $185. From 5 pm: individual $150, couples $165, family $195. Same rates in Wollongong, Dapto and Zoom. No rebates. Give at least 48 hours’ notice to cancel/change; less notice or non-attendance incurs the full fee, subject to agreed exceptions and applicable rights. Reduction/waiver may be considered for serious or unexpected circumstances. Do not enter card numbers, expiry dates or security codes in this form; payment is handled separately through the practice’s approved service.

I have read the fee information

I need the fees explained before proceeding

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Payment Details* This field is required.Card Number

Card Number

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Expiry Date* This field is required.Card Expiry (MM/YY)

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CCV* This field is required.Security Number

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Collection notice and intake decision* This field is required.RCS-Health trading as The Counselling Wollongong Studio (ABN 61 529 395 719) collects intake information to assess suitability, prepare counselling, manage appointments and billing, maintain records and meet relevant legal/professional responsibilities. Some provider/subprocessor processing may occur overseas. Necessary information may be needed before safe service can proceed; ask to discuss sensitive or unknown details. You may request access/correction and raise privacy concerns.

I have read this information and want to send my intake form

I want to send my intake and discuss questions about this information