Intake Form

Name *

First Name

Last Name

Date of Birth

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Address

Address 1

Address 2

City

State/Province

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Terms and Conditions *

Appointments: • The length of an appointment is 50-60 minutes and costs $135 until 5pm, or $150 after 5pm or on weekends • A 24-hour cancellation fee of $30 applies for all appointments that are cancelled with less than 24 hours notice of your scheduled appointment and/or for no-shows Confidentiality: • All information shared between you and your counsellor is confidential • Information will not be released without your written consent or unless required by law • Your counsellor is bound by law to disclose any information regarding suspected abuses and threats of harm to yourself or others • Courts can subpoena counselling records • At times Health Insurance Companies may require information regarding your treatment and diagnosis. This will only be provided with your written consent • Release of client notes can only be done so in accordance with the Privacy Act 1988 (Cth) Fees: • The client is required to make payment of fees at the time of service • Counselling services are not currently eligible for a Medicare rebate • The client seeking counselling services is financially liable for all fees, with the exception of people under the age of 18 whereby other arrangements will be made with your counsellor

I have read and understand and agree to the policies of this counsellor. I have been offered a copy of these policies to take with me if requested. I agree to accept financial responsibility for payment of charges incurred. I understand that a re-billing fee/financial charge complying with State Law will be applied to any overdue balance.

Todays Date

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