Dom Lawrenson - New Client Intake & Consent Form

New Client Intake & Consent Form

As part of providing a counselling or coaching service to you, I (Dom Lawrenson) need to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing counselling services to you. This collection of personal information will be a necessary part of the counselling assessment and therapy that is conducted. Your personal information is gathered as an essential part of your counselling and therapy. It is kept securely and, in the interests of your privacy, used only by me (your counsellor). Your personal information is retained in order to document what happens during sessions, and enables me to provide a relevant and informed counselling service to you. A more detailed description is provided in Dom Lawrenson Counselling’s Clients’ Rights and Protecting your Privacy document that can be obtained on my website. This document contains information about how to access and seek collection of your personal information, or how to lodge a complaint about the management of your personal information.

What type of counselling are you interested in? *

Individual Counselling (One person)Couples Counselling (Two people)Clinical supervision (Counsellors only)

Client Details

Family Name *

Given Names *

Preferred Name

Preferred Pronouns

D.O.B. *

Gender (Not Compulsory).

Street Address *

Suburb *

Postcode *

Contact Details

Mobile *

Email *

It is necessary to call, text and email you on occasions. Much of this is to confirm appointments and provide information. This can include details of online appointments and alerts relating to availability. Do I have permission to contact you? *

Yes, I would like occasional emails with updates and wellness tips. (Normally 1 or 2 a month).

If contacting you puts you at risk of domestic violence or could potentially create danger in any way please either mention it here or call and discuss with me in confidence.

Other Information

Have you had counselling before? If 'yes' let me know when and for what reason.

Indicate 'yes' or 'no' if you have been diagnosed with a mental health issue. If yes please provide brief details. *

Primary reason for counselling now. *

What are the goals you want to achieve from counselling?

How did you find me? *

Country of Birth (not compulsory).

Nationality (not compulsory).

Private Health Funds.(My services are covered by BUPA, Medibank, AHM Police Health & Doctors Health Fund – dependant on your policy/eligibility).

Preferred Days and Times for Appointments.

Emergency Contact Details

Used only in an Emergency (E.g., if you became ill at a session, or if you are assessed as potentially at risk to yourself or others). Not used otherwise without your permission.

Name *

Relationship *

Phone *

Client Conduct

Counselling needs to be a safe space for all and positive outcomes usually come from respectful communication from everyone concerned. It is necessary to remind clients that aggressive behaviour that undermines the positive intention of therapy will not be accepted and if continued could result in the counselling being cancelled. This policy protects everyone concerned and also paves the way for clients to gain the most value from counselling. Please confirm that you understand and agree to this statement.

Yes *

Acknowledgement

Fees:

Individual Counselling sessions are $120 for one hour, $90 for 45 minutes, and $60 for 30 minutes, and are paid in advance online. Couples Counselling sessions are $185 for one hour and are also paid in advance online. Please note that all couples have an individual 90-minute session before the couples' sessions commence.

If you provide less than 24 hours' notice or do not show up, the full counselling fee will be payable.

Please also keep in mind that you, the client, or I, the counsellor, can terminate this agreement at any time. It is also perceived that the contract has ended after three months of disengagement, and it would normally be necessary to complete the current Consent/ Intake Form at that time.

Client Consent:

A consequence of not providing personal information:

If you do not wish for your personal information to be collected in the way detailed in this document, I may not be in a position to provide the counselling service to you.

Access to client information:

At any stage, you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. I can discuss with you different possible forms of access and can discuss the information with you.

Disclosure of personal information:

My counselling service provides a confidential service that includes regular and appropriate consultation between myself and experienced supervisors.

All personal information gathered by me during the counselling service will not be disclosed outside my practice except when:

Failure to disclose the information would, in the reasonable belief, place you or another person at serious risk to life, health or safety; or
It is subpoenaed by a court; or
Your prior approval has been obtained to discuss this material with another person, e.g. parent, lawyer, or
Disclosure is otherwise required by law.

Your personal information is not disclosed unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.

I have read and understood this Consent Form and Dom Lawrenson Counselling’s Clients’ Rights and Protecting Your Privacy document. I agree to the above conditions for the counselling service provided by Dom Lawrenson Counselling.

I understand that by signing this Consent Form, I permit my counsellor to consult with other agencies or persons as stated in this consent form.

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Please note: If, after reading this form, you are at all unclear about any of the information provided, please discuss this with me.

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