Personal Information FormPlease take your time to fill out this form (one for each Client) and understand our Confidentiality, Privacy and Cancellation Policies.Leaving this page prior to clicking ‘Submit’ will erase all completed fields. Personal details Name * First Name Last Name Preferred name (if different) Email * Phone number (mobile preferred) * (Format example: 040 772 2909) (###) ### #### Street address & Suburb Postcode Date of Birth (Please note American format: Month, then Day and Year) MM DD YYYY In case of an emergency, please contact: * Emergency contact phone number (mobile preferred) * (###) ### #### Relationship status Married Single Living with someone Separated Divorced Your Partner's name (if applicable) Names and ages of children (if applicable) Occupation (if applicable) Medical History Do you smoke cigarettes? Yes No Number of standard alcoholic drinks consumed per week (zero if non-drinker) Type and frequency of any illicit drugs regularly consumed Have you ever been treated (or are now under treatment) for any of the following conditions? Anxiety Heart Disease Epilepsy High Blood Pressure Asthma Diabetes Allergies Have you ever been treated (or are now under treatment) for any mental illness? (please specify) Is there any other medical information you would like to advise? Is there any other information you would like me to know before we begin our session? Confidentiality, Privacy and Cancellation Policies Confidentiality * Information regarding your attendance to counselling sessions will generally not be disclosed without your consent. With regards to couple counselling, any communication between the counsellor and one of the couple may be communicated openly with the other partner at the counsellor's discretion. You should also be aware that information relevant to your care and well-being may be shared with my supervisor, so that we can work together to provide you both with the best possible service. In accordance with professional responsibilities and/or legislation, I may need to disclose details to other persons in the following circumstances: • I have a reasonable belief that there is a risk to your health or safety or that of another person • there is a legal requirement to do so • it is necessary to obtain legal advice. In some of these circumstances, it may not be possible or practicable to seek your consent. However, every effort will be made to consult with you in the first instance. I have read, understood and agree to Eastern Couple and Individual Counselling's Confidentiality Policy. Privacy and Record Keeping Personal information gathered from you will be used for the primary purpose of your care. If you do not provide the information requested, I may be unable to provide you with services or respond to your requests for additional support or referrals. I maintain individual and/or couple files. This will contain records of any contact, key discussion points, outcomes and other relevant information provided during the counselling sessions with you. All files are stored in a secure and safe location. Client files are retained for a minimum period of 7 years after completion. I have read, understood and agree to Eastern Couple and Individual Counselling's Privacy and Record Keeping Policy Cancellation and Payment * In our commitment to provide the highest possible outcomes to all our clients, late arrival may result in a shortened session time to accommodate appointments following you. Full payment for your session will be required. If for any reason you cannot keep your appointment, please advise us immediately (0419 567 703). Cancellations received with less than 24 hours' notice will be charged at the standard rate. These policies have been adopted to ensure that the professionalism and ethics of our clinic are respected, and to ensure your session is a productive and beneficial experience. Please note payment for service is required on the day of service. Cash, EFTPOS or Credit Card or previously cleared bank transfer are acceptable. If you have any questions about our policies, please contact us at: info@easterncouplecounselling.com.au I have read, understood and agree to Eastern Couple and Individual Counselling's Cancellation and Payment Policy Thank you!
