New Client Form

Please provide the information requested below. It will be kept confidential in your file. Please advise of any changes.
Name *
Name
Address *
Address
Relationship Status *
Children *
If you prefer to discuss this in person please leave this section blank.
(Please note that for couple consultations, the information in this space will be discussed with you and partner in the joint sessions)
Have you ever experienced:
Please list condition, date diagnosed and treatment.
Please list the medication name, reason taken, and the dosage taken per day.
Please provide the name of any current or recent healthcare providers (GP, Specialist, Psychologist, Counsellor, Kinesiologist, Psychiatrist, Naturopath/Homeopath, Physio, Chiro, Osteo, Other) and the date of your last visit.
How did you hear about me? *
Would you like to receive my newsletter? *
Cancellation Policy

Business hours are Tuesday-Saturday.

Please note that 48 business hours notice is required to cancel or reschedule a session. Missed appointments, cancellations and rescheduling with less than 48 hours notice will incur a full session fee.

Please note that emails, sms messages and voicemails are not monitored on Sundays and Mondays as these days are outside business hours.

Cancellation Policy Agreement *

If you are booked on a Tuesday, and need to or cancel or reschedule an appointment, it is necessary to have contacted me by Friday morning to do so.

If you are booked on a Wednesday, and need to cancel or reschedule an appointment it is necessary to have contacted me by Saturday morning to do so.

*
Payment
Please note for ease of administration payment is taken at the beginning of every session.
Confidentiality Statement

Under Australian law, counsellors are obliged to maintain client confidentiality.

Information about clients who seek counselling, the nature of the service provided, and the content of the counselling sessions, will not be disclosed without the permission of the client.

There are, however, some circumstances where exceptions apply. Counsellors may be required to disclose communications where the counsellor or practitioner reasonably believes that disclosure is necessary to:

  • protect a child from the risk of physical, emotional or psychological harm;
  • prevent or lessen a serious and imminent threat to the life or health of the client or other any person, including the threat of suicide; or
  • report the commission, or prevent the likely commission, of an offence involving violence or a threat of violence to the client or any other person.
  • comply with a law of the Commonwealth or a state or territory. This includes, for example, mandatory reporting of children at risk of harm either physical or emotional under state and territory laws and when client files are subpoenaed by a court of law.

As part of good practice, counsellors are required to undertake professional supervision with qualified and experienced therapists whose role is to guide and advise. Your case may be discussed in these circumstances as part of good case management. Your name will not be disclosed in accordance with maintaining your privacy and confidentiality.

Confidentiality Statement Agreement *
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