Intake Forms – counsellingwithequipoise

Confidentiality and Client Informed Consent

Introduction

As part of the provision of service to you, including but not limited to counselling, assessment, treatment and
report writing, Counselling with Equipoise needs to collect and record personal information from you. In
accordance with relevant privacy and confidentiality legislation, the information collected may include (but
may not be limited to) your name, contact details, emergency contacts, medical history, and other relevant
information as appropriate. The collection of this information is a necessary part of your participation in
Counselling/Therapy. Your informed consent must be given prior to commencement of services.

Privacy and Confidentiality

Your personal information is gathered as part of the service you are engaging in. Information is securely stored and is retained in order to document what occurs during sessions. This helps the Counsellor to provide a tailored service specific to your needs.

Limits to Confidentiality

All personal information gathered by Counselling with Equipoise during the provision of services remains
confidential except when:

It is subpoenaed by a court; or
Failure to disclose the information would, in the reasonable belief of Counselling with Equipoise, place you
or another person at serious risk to life, health or safety; or
Your prior approval has been obtained to:
A) provide a written report to another professional or agency;
B)discuss the material with another person;
C) disclose the information in another way; or
You would reasonably expect your personal information to be disclosed to another professional or agency
(e.g., your GP) and disclosure is directly related to the primary purpose of collection; or
Disclosure is otherwise required or authorised by law.

Consequence of Not Providing Personal Information

If you do not wish for your personal information to be collected in a way anticipated by this consent form, Counselling with Equipoise may not be in a position to provide the Counselling service to you.

Confidentiality and Client Informed Consent

Date

Full name

Preferred Name

Gender

Preferred Pronouns:

Date of Birth:

Relationship Status:

Occupation:

Mobile:

Email:

Home Address:

Emergency Contacts

Emergency Contact 1 - Name:

Relationship to you:

Phone

Emergency Contact 2 - Name:

Relationship to you:

Phone:

Mental Health & Medical History

Are you currently under the care of a GP, Psychiatrist, or other mental health professional?

Primary Care Practitioner (GP)

Phone:

Psychiatrist - Name:

Phone:

Other Professionals

Contact:

Have you ever been diagnosed with a psychological disorder?

If yes, please specify:

Have you ever been hospitalized for a psychiatric illness?

If yes, please specify:

Are you experiencing any immediate safety concerns such as suicidal thoughts or self-harm?

Have you ever experienced suicidal ideation?

Have you ever attempted suicide?

Have any family members ever attempted or committed suicide?

Do you have any issues with substance abuse?

Do any family members struggle with substance abuse?

Have you ever been arrested?

Do you have any impending court cases?

Please list any medical conditions, previous or current:

Therapeutic Goals & Expectations

Briefly describe your reasons for seeking counselling:

What are you hoping to gain from therapy?

Acknowledgment & Consent

Client Name:

Date:

Confidentiality and Client Informed Consent

Introduction

Privacy and Confidentiality

Limits to Confidentiality

Consequence of Not Providing Personal Information

Confidentiality and Client Informed Consent

Emergency Contacts

Mental Health & Medical History

Therapeutic Goals & Expectations

Acknowledgment & Consent

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Acknowledgement of Country

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Quick Links

Services

Acknowledgement of Country

Allright Reserved - Developed By Arch Digital Service.