Counselling Intake Form

Step 1 of 5

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Client Information

Your Name(Required)

Title First Name Surname

Date of Birth(Required)

Day

Month

Year

Occupation

Employment

Full-time

Part-time

Unemployed

Retired

On Leave

Student

Self-Employed

Address

Address Suburb Post Code

Phone (Home)

Phone (Work)

Phone (Mobile)

Your Email Address(Required)

Marital Status

Any Children?

referred by (if applicable)

Availability (days/times)

Mon

11am

1pm

3pm

5pm

Tue

11am

1pm

3pm

5pm

Wed

11am

1pm

3pm

Thurs

11am

1pm

3pm

5pm

Fri

11am

1pm

3pm

5pm

Session Preference

Via:

Zoom

Skype

Please provide contact infor for chose preference

Contact Preferences

Would you prefer I contact you by:

Phone

If you prefer to be contacted by phone, for reasons of confidentiality, please advise if I can contact you and/or leave a message at the numbers you have provided.

Home

YES

Work

YES

Mobile

YES

Counselling History

Any previous therapy (e.g. Counsellor, Social Workers, Psychologists, Psychiatrists etc)?

Medical History

Doctor name

Doctor Phone

Prescribed Medication

In case of an emergency who should be contacted?

Name

Phone

Relation To You

Presenting Issues

(tick ALL that apply)

Anxiety

Work Stress

Depression

Forgiveness

Getting Unstuck

Loneliness

PTSD

Stress

General Mental Health

Couples/Relationships

Grief

Social Anxiety

Student Life

Weight Management

OCD

Other

Please provide a brief description of the current presenting issue

What are you hoping to see change as a result of counselling?

Agreement(Required)

• I have read, understood and completed this intake form with accuracy and to the best of
my knowledge.
• The session will run for about 55 minutes, with a 5 minutes summary towards the end.
• Everything said within the session will be confidential.
• Notes taken during the counselling session are for case study purposes and will remain
confidential.
• If I feel as though you may be at risk of harm to yourself, to another or to a child, or if there
is a situation where a judge orders a subpoena to see our notes, only then confidentiality
may need to be breached.

I agree.

Name of Client(Required)

Signature(Required)

Date(Required)

If Client under 18 years of age:

Parent/Guardian Name

Parent/Guardian Signature

Date