New Client Form

Name

First Name

Last Name

Date of Birth

City & Country of Birth

Landline Phone

Mobile Phone

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

Hobbies

Relationship Status

Married

Single

In a Relationship

Widow/er

De Facto

Divorced/Separated

Other

Children

Yes

Ages of Children

Reason for visit?

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)

What is your availability?

Please provide the days and times you are available to attend an initial appointment and ongoing appointments.

Initial Appointment

Please provide preferred day/s and preferred time/s of day.

All follow up appointments

Please provide preferred day/s and preferred time/s of day.

Medical Conditions

Please list condition, date diagnosed and treatment.

Current Medications/Supplements

Please list the medication name, reason taken, and the dosage taken per day.

Other Healthcare Providers

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.

Health Fund

Counselling sessions can be claimed with some health funds. Please indicate your health fund below if you would like to claim your counselling sessions. Note: To find out whether your private health plan covers counselling, please contact your health fund directly for information regarding rebates for registered counsellors.

How did you hear about me?

Website

Natural Therapy Pages

Another Healthcare Provider

Business Card

Friend/colleague

Flyer

Other

Would you like to receive my newsletter?

Yes

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.

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

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

I have read, understood and agree to the cancellation and rescheduling policy explained above.

Name

Date

Fees and Payment

Individual Consultation: Standard Consultation 55 mins: $264 Couple Consultation: Standard Consultation 55 mins: $308 All appointments include GST. Please note that accounts are not given. Payment is requested before or at the beginning of your session. Payment can be made via electronic transfer or debit or credit card (VISA and MasterCard). Please note card processing fees apply. I will email you a receipt once payment has been received.

Fees and Payment Agreement

I have read and understand the fee structure and that payment is required before the session or at the beginning of the session.

Name

Date

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

I have read, understood and agree to the confidentiality statement explained above.

Name

Date

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