Personal details

First Name *

Last Name *

Preferred name (if desired)

Preferred pronoun (if desired)

Date of birth *

Home address *

Email address *

Best phone number *

Cultural factors

In which country were you born?

In which country was your mother born?

In which country was your father born?

What is your faith?

Mental health history

Are you currently engaged in any other psychiatric services, professional counselling or psychotherapy? *

NoYes

Please provide the name and/or job title of the professional you're seeing.

Have you previously engaged in any other psychiatric services, professional counselling or psychotherapy? *

NoYes

Please provide the name and/or job title of the professional you saw most recently.

Are you currently taking any prescribed medications for mental health issues? *

NoYes

Which medications and dosages are you currently taking?

Has a doctor diagnosed you with any of the following conditions at any time in your life?

Please include any other information regarding your mental health that you think might be helpful for your therapist to know.

Which family member(s) experience(d) depression?

Which family member(s) have been diagnosed with an anxiety disorder?

Which family member(s) have been diagnosed with a panic disorder?

Which family member(s) have been diagnosed with post-traumatic stress disorder?

Which family member(s) have been diagnosed with a bipolar (or related) disorder?

Which family member(s) have been diagnosed with schizophrenia?

Which family member(s) have been diagnosed with borderline personality disorder?

Which family member(s) have been diagnosed with narcissistic personality disorder?

Which family member(s) have been diagnosed with obsessive compulsive disorder?

Which family member(s) have experienced alcohol/substance abuse or addiction?

Which family member(s) have experienced an eating disorder?

Which family member(s) have attempted or completed suicide?

Lifestyle

Do you exercise? *

NoYes

How many days per week do you exercise?

What type(s) of exercise do you like to do?

Are you currently experiencing any sleep problems? *

NoYes

Please indicate the nature of your sleeping problem.

Too muchNot enoughDisturbedNightmares

Are you having any difficulty with appetite or eating habits? *

NoYes

Have you experienced any significant weight change recently? *

NoYes

Please indicate the nature of your recent weight change.

LossGain

Roughly how much (in kilograms) have you lost?

Roughly how much (in kilograms) have you gained?

Relationships and major life events

Are you currently in a romantic relationship? *

NoYes

For roughly how long have you been in that relationship?

If you selected 'other', please give a brief description of the major life change or event you've experienced recently.

Work

Are you currently employed? *

NoYes

What is your occupation/position?

How satisfied are you at work?

Very satisfiedSatisfiedDissatisfiedVery dissatisfied

Emergency contact

Please give the details of someone I can contact if an emergency arises during session.

Emergency contact name *

Emergency contact phone number *

Relationship to emergency contact *

Cancellation policy

Cancellations with more than 24 hours’ notice may, at the therapist’s discretion, incur a fee of $30, payable before the subsequent session.

Cancellations with less than 24 hours’ notice may incur a fee of 50% of the fee that would have been payable, to be paid before the subsequent session.

Non-attendance without cancellation may incur a fee of 75% of the fee that would have been payable, to be paid before the subsequent session.

I have read and understood the cancellation policy. *

Confidentiality agreement and informed consent

All information discussed during counselling sessions is treated with the utmost regard for confidentiality.

Please note that phone calls, SMS/text messages and email communications with your therapist are not encrypted, so should be used only for organising appointments and other logistical purposes.

All registered counsellors and psychotherapists are required to attend regular supervision, which involves discussion of specific issues arising from their work. This is to ensure client safety and quality of service. Details of your sessions may be shared with a supervisor, but you will not be identified.

There are only two situations in which identifying information may be shared by the therapist:

With another health professional(s) or the client’s nominated support contact, if the client’s safety, or the safety of others, is clearly compromised. Whenever possible, this will be done with the client’s express permission.
When subpoenaed by a court to serve as evidence.

Therapists' notes are stored in hard-copy only in a locked cabinet and destroyed after a period of seven years, in line with the Victorian Health Records Act (2001). In the case of clients under 18 years of age, records are retained until the client turns 25.

I confirm that I have read the above information and understand the limits to confidentiality in online counselling. *

By signing below, I confirm that the information I have provided on this form is true and accurate to the best of my knowledge.

Signature *

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Parent/guardian signature (if under 18 years)

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