Personal details

First Name *

Last Name *

Preferred name (if desired)

Preferred pronoun (if desired)

Date of birth *

Home address *

Is this the address you'll be at during our sessions? *

YesNo

Please note: in case of emergency, it is very important that your therapist knows where you are located during your online sessions. If you attend a session from any address other than the one you've indicated on this form, please let your therapist know the new address as soon as possible.

Please give the address where you will be located during our sessions.

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

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

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?

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

Suitability for online counselling

Online counselling is different to face-to-face counselling in a number of ways, and requires that clients take a greater level of responsibility for ensuring the confidentiality of sessions and the quality of the online connection.

A response of 'No' to any of the following questions may mean that online counselling is not appropriate for you at this time. If you answer 'No', but intend to fix the problem before the first session, that's fine.

If your internet connectivity is a problem for any reason, it may be preferable to conduct sessions over the phone. Please discuss this with Tim if you're unsure.

Do you have a safe, private, uninterrupted, indoor space from which to attend online sessions? *

YesNo

Do you have a desk or table to sit at? *

YesNo

It is not appropriate to attend counselling on or in a bed, or on the floor.

Do you have a computer or tablet you can use for the sessions? *

YesNo

It is important that you are able to see the therapist's face as clearly as possible, so it is not appropriate to use a smart phone or any device smaller than a tablet.

Does your webcam work and is the picture clear? *

YesNo

Does the lighting near your screen make it easy to see your face and facial expressions? *

YesNo

Light reflected from your computer screen alone is not adequate to light your face. A combination of a desk lamp and overhead lighting is ideal.

Does your microphone work and is the audio clear? *

YesNo

If you live with other people, do you have a headset, headphones or ear buds that you can use?

YesNo

It is highly recommended to use some kind of headphones to help protect the confidentiality of your session.

Do you know how to use your smart phone as a mobile hotspot in case of wifi connectivity problems?

YesNo

For instructions on tethering Android phones, please visit: https://support.google.com/android/answer/9059108?hl=en. For instructions on tethering iPhones, please visit: https://support.apple.com/en-au/HT204023

Support person

All online clients are required to provide the details of a 'support person', someone who is contactable if a crisis or emergency situation arises during a session.

The support person can be someone you live with or someone who lives nearby (within, say, five kilometres) who would be able to physically check on you in case of emergency.

Please check with your support person that they are agreeable to being contacted in case of an emergency.

Please let them know that they will ONLY be contacted by your therapist in case of emergency to help ensure your safety.

Have you asked someone you live with or who lives nearby to be your 'support person'? *

YesNo

If you're unable to ask a support person right now, please ensure you email their details to Tim at tim@timeandspacetherapies.com.au as soon as possible before your first session.

What is your support person's first name?

What is your support person's best phone number?

Cancellation policy

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

Non-attendance without cancellation may incur a fee of 75% of the fee that would have been payable. This will be automatically deducted from your stored credit card.

Cancellations at the time of the session due to technical difficulties will be treated as non-attendance. It is the responsibility of the client to ensure well in advance of each session that all technological components are working adequately. A cancellation fee may be deducted automatically from your stored credit card.

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.

The online counselling platform used at Time & Space Therapies is Coviu, which offers end-to-end encryption, the highest standard of encryption available.

Despite this, no online platform is perfect. While every reasonable precaution is taken to protect your privacy, and attacks on privacy are highly unlikely, all online platforms may be susceptible to hacking or other confidentiality breaches.

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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