Client Welcome Form Nationwide

Client Welcome Form Nationwide

ABN: 55 637 079 620
Take note: If a participant makes a short-notice cancellation, which is after 3pm the day before the service, the provider will charge 90% of the agreed price for the cancelled appointment.

For other cancellations, where the participant has provided notice of cancellation prior to 3pm the day before the scheduled service, no cancellation fee will apply.

To cancel, please call and email the head office at: (07) 4864 9888 | contact@empoweredtherapyandtraining.com
Therapy or service required (please tick all that apply):

Other
Location of Service:

Other
Client/ Participant Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:

Other
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Children:
Current Marital Status:

Other
Current Employment Status:

Other
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Format: (000) 000-0000.
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to you:
How did you hear about us?
Referred by:

Other
Please provide the details of who referred you:
Starting date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
How many sessions are you granted?
What do you do in your spare time? Hobbies, interests, etc.
Prior Life Experience
Which of the following have you experienced (either currently or in the past)? Please tick all that apply:
Which of the above continue to be a problem for you?

Please answer yes or no for the following:

Rows	Yes	No
Do you have current concerns about alcohol use?
Do you have concerns about illegal drug use?
Do you overuse prescription medication?
Do you have concerns with gambling?
Do you have concerns with excessive Internet use?
Do you have concerns with Internet porn use?
Do you have current thoughts of suicide or plans for suicide?
Have you ever attempted suicide?

Intensity of suicidal thoughts:

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Intent to carry out suicidal thoughts:

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
If you have ever attempted suicide, how many times, method and at what age(s)?
Are you currently taking medication?
If yes to the above, please list them below:
Past Therapy Experience
Have you received previous therapy in the past?
Have you been assessed in the past?
If yes to the above, please provide the date of assessment:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Do you think it was helpful?
Please provide details of why it was/wasn't helpful:
Goals for this service
What are your main concerns/issues?
How long have you been concerned about this?
What are your main three goals for this therapy?
Please list all the previous assessment/therapy services received in the past year:
Do you give Empowered Therapy & Training permission to contact other health professionals, stakeholders etc in regards to assessment/therapy to ensure open communication and comprehensive assessment?
Please list other health professionals or stakeholders etc which you give EmpoweredTherapy and Training permission to contact:
If you would like to make a complaint, or provide positive feedback regarding your experience with us, you may go onto our website to fill out our feedback form. Do you understand?
Client/ Participant/Parent/Guardian Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

Client Welcome Form Nationwide

Emergency Contact

How did you hear about us?

Prior Life Experience

Past Therapy Experience

Goals for this service