Mindful Keeping Intake Form

Please review and sign this intake form before your first appointment. The information you provide here will be kept confidential. If you have any questions, please feel free to ask.

Thank you for choosing our practice to seek support. We value and prioritise creating an inclusive and safe environment for all individuals. To better serve you, please provide us with the following information.

Name *

Phone/Mobile *

Email *

Date of Birth *

Address You Currently Reside At *

Gender *

Male
Female
Other

Current Relationship Status *

Single
Married
Divorced
Separated
Widowed
Partnered

Do you have children? *

If yes, please specify and include ages. *

Emergency Contact Person *

Emergency Contact Phone Number *

If you are working, what sort of work do you do? *

Level of Education *

Referred By: *

Self
Other

If other, please provide details. *

In a few sentences, please provide the nature of the presenting problem that brings you to counselling. *

In a few sentences, please state what you are hoping to get out of your therapy sessions. *

What goals are you wanting your Counsellor to support you with throughout the therapy process? *

Please list any physical health issues that you consider relevant to our working together. *

Do you have any accessibility requirements or preferences to attend the counselling practice (i.e. wheelchair access)? *

What prompted you to make this appointment? *

Do you have a diagnosed mental illness? *

If yes, please specify. *

Do you experience any of the following? Anxiety, depression, suicidal ideation, panic, anger, trauma, relationship conflict, addictions, grief and loss, self-harm tendencies. Please specify. *

Do you have any family members that have been diagnosed with a mental health condition? *

If yes, please specify. *

Are you funded for counselling under the National Disability Insurance Scheme (NDIS)? *

Have you had previous counselling? *

If yes, how long ago? *

Are you currently receiving counselling, psychology or psychotherapy services elsewhere? *

If yes, please specify. *

Are you currently taking any medications (antidepressants or other)? *

If yes, please specify and provide details if relevant. *

Checkboxes *

I am aware that each booked counselling session will run for sixty (60) minutes, and I will provide a minimum of twenty-four (24) hours' notice if I am unable to attend the agreed appointment time via phone call or SMS to my therapist. I understand that failing to turn up or cancelling on the day may incur a cancellation fee payable prior to my next appointment, unless it is due to unforeseen circumstances where the decision of payment will be at the discretion of my therapist.

By typing your name in the follow box you are confirming that everything in this form is true and accurate. *

Signature *

Use your mouse or your finger to sign in the box above. Click the X in the top-right corner if you need to clear the box and start again.

Today's Date *

Thank you for completing this form. Please be assured that your privacy with regard to the use and storage of this information will be respected in line with our Privacy Policy and the Australian Privacy Principles stated in the Privacy Act 1988 (Cth).

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East Maitland NSW 2323

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Mindful Keeping Intake Form

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