New client intake form

Please fill out this form and submit it. Take your time; the more detail you can provide the better our sessions will be.

Also please read my terms and conditions at the bottom of the page. Information submitted via this page is done so securely and privately.

    Have you ever been diagnosed with a psychiatric condition or illness?

    In the past, have you undergone any sort of therapy or counselling?

    Do you have a medical condition that may present in the therapy room?

    Are you currently on any medication?

    Do you self medicate with alcohol, tobacco, food, prescription drugs, over the counter or recreational drugs or any other addictive behaviours?

    Are you currently, or have you ever been suicidal?

    What was significant in your formative years?

    Agreement / Terms & Conditions

    To lay the foundation of our therapeutic relationship, please read the following agreement. 

    Clients should not sign this contract unless they have read and understood the clauses therein and had any questions answered to their satisfaction.

    1. The writer of this contract was trained in accordance with the Psychotherapy and Counselling Federation of Australia (PACFA) guidelines and as such abides by the PACFA code of ethics which can be found on the PACFA website:
    2. It is agreed that therapy results are not guaranteed. The client enters into therapy with the understanding that he/she/they is/are responsible for creating his/her/their own results and that the therapist will work towards facilitating the client’s development.
    3. The therapist will decline to work with certain clients if she believes that she does not have the expertise to provide optimum care. In such cases, the therapist will refer the client to an appropriate therapist or agency.
    4. Therapist records of session dates and any session notes will be stored in a secure manner. Clients may request to see records pertaining to their sessions at any time.
    5. The therapist may share such information as she deems necessary for supervision with her therapy supervisor whilst maintaining the client’s anonymity. This is part of the therapist’s ongoing professional development.  At no time will clients be named or identified.
    6. The therapist shall not be liable for the death or injury of the client or loss of property of the client, unless this is due to negligence or other failure of the therapist to perform her obligations under this agreement or under general law.
    7. The client shall agree not to intentionally harm the therapist, property of the therapist or any other person or property during the time of the therapy contract.
    8. It is agreed that the therapist will listen to and consider all the information given by the client and will not give that information, either verbally or in written form to any other person in any circumstances whatsoever, (other than in supervision as per #4 of this agreement), unless:
    9. Legally required to do so in the course of a police investigation.
    10. Required to answer questions in court having been told by the court to give evidence.
    11. The therapist believes that the health or safety of the client or another person is at risk
    12. Where a failure to give information would lead to the conviction of the therapist
    13. There are child protection issues which would necessitate working in partnership with a child protection team or specialist.
    14. The client discloses involvement in criminal activity
    15. The therapist will not contact anyone else about the client without the consent of the client except in circumstances where the therapist believes that there is a significant risk to the client’s safety, property or other persons. In such cases all efforts will be made by the therapist to obtain the consent of the client to involve a third party – usually the client’s nominated emergency contact person.  If consent is not obtainable for whatever reason, the therapist will make every effort to inform the client of her intention to contact a third party.
    16. While most communication will be face to face, or via zoom during sessions, there may be some occasions when the therapist may need to contact the client via text or email (e.g. confirmation of appointment time, referral information etc.). Should the client not wish to be contacted in this manner it is the client’s responsibility to inform the therapist.

    Cancellation Policy

    24 hours notice of cancellation of a session is required from the client. When less than 24 hours notice is given, 50% of the fee will apply except in circumstances of accident or emergency. 

    Should the therapist need to cancel a session with less than 24 hours notice, the subsequent session will be billed at 80% of the regular fee.