IndividualIntake - Tess Counselling

First Name*

Middle Name*

Last Name*

Birth Date*

Email*

Address*

Home Address Suburb State Postcode

Mobile*

Home Phone*

Work Phone*

What has brought you to counselling?*

What changes would you like to occur, as a result of this counselling?*

Are you presently engaging in counselling elsewhere?*

Yes
No

If so, with whom?

For how many sessions?

What issues are you addressing with them?

Have you previously engaged in counselling?*

Yes
No

If so with whom?

Approximate number of sessions / length of time?

How long ago?

What was that/those counselling experiences like for you?

Please list any medications you take for mental health reasons:*

What made you choose this counselling practice?*

CONFIDENTIALITY:

Any information shared during counselling will be respected and kept in confidence. However many settings place additional specific limitations on confidentiality - sincere attempts will be made to discuss such situations with you before any relevant reporting is undertaken. Such reporting is done only in an attempt to ensure the safety and well being of either yourself and/or others.

Do I have your permission to contact you via ....*

Phone
Text (SMS)
Email

Consent

I agree to the privacy policy.

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