Intake & Consent Formhello@thelifeconsultant.co(+61) 497-493-042 ALL ABOUT YOU Name * First Name Last Name Email * Phone Country (###) ### #### Can I text and call you on this number? * Yes,that's fine No, do not contact me via this number. Email only. Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Gender Male Female Other Prefer not to say Employment Status Full Time Part Time Student Retired Home worker Unemployed Other How did you hear about TLC? ALL ABOUT FAMILY Relationship Status Single Married Partnered Dating Divorced Separated Widowed Do you have any children? Yes No I would prefer not to say ALL ABOUT HOW WE CAN HELP Have you seen a therapist or coach before? Yes No If yes, when? And how would you describe your experience? Why did you book in to see us? Anything else going on right now? Stress Work related issues Family related issues Relationship breakdown Anxiousness Lack of motivation Self-esteem issues Grief & Loss Trouble with sleep Health/medical issues How severe is your situation I am highly distressed I am moderately distressed I am minimally distressed I am not distressed Please list any current medications EMERGENCY CONTACT Emergency Contact Person's Name First Name Last Name Relationship to you Emergency Contact Phone * Country (###) ### #### CLIENT CONSENT FORM Therapy & Coaching Services Providing a consulting service means that I will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the consultation. You do not have to provide us with all your personal information, but this may impact the service that we are able to provide. Privacy Any information is gathered as part of the consultation service and is seen only by myself. The information is retained in order to document what happens during sessions, and enables me to provide a relevant and informed service. At any stage you as a client are entitled to access the information kept on file about you. I may discuss with you the appropriate forms of access. Confidentiality Please be assured that all information provided in the process of consultation will strictly remain confidential and secure. Other than the special circumstances outlined below, no information may be released to others without the written consent from you . These special circumstances include the following: 1. Where a court orders the release of client information for legal purposes 2. Failing to disclose the information would place you or another person in serious or imminent risk. 3. Your prior approval has been obtained to provide a written letter or report to another other agency (eg: GP) or discuss the material with another person (eg: parent, employer) 4. If the disclosure is required by law. Fees The cost of consultation varies depending on your selected service. The agreed upon payment is due via thelifeconsultant.co website, invoice or in person. In special circumstances, discounts may be applied. The revised cost will be discussed and agreed upon prior to the first session and payment of the amended amount will be required before the session begins. All prices are in AUD. If you elect to pay by monthly instalments, payment must be received by the 1st of each month you are in the Program, over the first 3 months or dates as agreed upon. If you elect to pay in FULL, payment must be made via thelifeconsultant.co website, invoice or in person, prior to the first session. Cancellation Policy If, for some reason you need to cancel or postpone your appointment, please give at least 48 hours' notice. If less than 24 hours' notice is given or if you fail to attend with no prior notice, you will be charged 100% of the full session fee. All cancellations to be made via email to hello@thelifeconsultant.co Thank-you in advance for your respect and understanding. Rescheduling Policy Appointments made via the online booking service can be rescheduled by you with no penalty, provided this is done 48 hours in advance of the initially booked appointment. Once payment is made for a session, fees are 100% non-refundable, but session fees can be applied to an appointment at a later date. Emergency & After Hours The Life Consultant does not operate as an Emergency or After Hours service. If you are in an emergency situation, please contact your nearest hospital emergency department, and if needed access Lifeline, which operates a 24hr crisis counselling telephone service on 13 11 14. CLIENT CONSENT * I HAVE READ THE ABOVE INFORMATION CORRECTLY AND CAREFULLY AND UNDERSTAND : Information about me will be collected for the purposes of the consultation session All fees to be paid in full prior to first consultation unless otherwise agreed The cancellation policy There are circumstances (outlined above) under which the confidentiality of the information I provide may be broken The Life Consultant does not provide emergency or after hours coverage and I know where to go to receive help if required I can withdraw from consultation at any time without prejudicing any future consultation requests The Life Consultant can withdraw from consultation at any time with verbal notice I have read and agree to ALL the TERMS & CONDITIONS above CLIENT NAME First Name Last Name CLIENT SIGNATURE I will submit this form electronically and by ticking this box agree to all the above terms and provide consent accordingly. Thank you! I can’t wait to meet with you soon! Please contact me on hello@thelifeconsultant if you have any questions prior to your session.
