Intake Form

Applicant Personal Information

Enter the details of the person attending counselling

First Name

Last Name

Date of Birth

Age

Legal Status

Parent / Legal Guardian

If the applicant is a minor, then details of their Parent/Legal Guardian are required.

First Name

Last Name

Education

Occupation

Employer

Relationship to the minor

Address Line 1

Address Line 2

City

State / Province

Zip / Postal Code

Country

Phone/Home

Phone/Work

Phone/Mobile

Marital Status of Applicant

Marital history for the applicant.

Marital Status

Spouse First Name

Spouse Last Name

Spouse's occupation

How long have you been married?

How many times have you been married?

How long have you been divorced?

Details of Dependants

Details of dependants or siblings. If needed, Click on the + sign to add more.

Children / Dependants

Name	Date of Birth	Sex	Relationship	Lives with you?

Counselling History

A brief history of any previous counselling/therapy.

Attendance

Previous Counselling?

When

Where

Reason for Counselling

Counsellor

Current Situation

Briefly describe the reasons why you would like counselling.

Describe Problem

Relationship

Referred By

Medical Information

A brief medical background.

Name of Doctor

Practice/Surgery Name

Phone/Mobile

Chronic Medication

Common Problems / Symptoms Checklist

Please select the symptoms for which you would like counselling, and indicate the severity of each.

Symptoms List

	Mild	Moderate	Severe
Marriage
Divorce/Separation
Alcohol/Drugs
Grief/Loss
Abortion
Past hurts
Family
School/learning
Fear
Anxiety
Low self-esteem
Mood swings
Anger
Control
Stress management
Fatigue
Impulsiveness
Sleeping difficulties
Irritability
Pre-marital
Being single
Other addictions
Sexual issues
Miscarriage
Church
Ministry
Spiritual
Weight control/change
Work/career
Money/budgeting
Employment
Trauma
Crisis
General unwellness
Sadness/depression
Violent behaviour
Nightmares
Loneliness/isolation
Child custody
Disability
Co-dependency
Intimacy
Infertility
Children
In-laws
Parents
Communication
Conflict
Loneliness
Aging/dependency
Friends
Uncertainty
Hopelessness
Disorganized thoughts
Easily distracted
Body image concerns

Special Childhood Circumstances

Religious / Cultural Beliefs

Consent Form

Client Rights

1. The client may ask questions about what to expect during and at the end of the recovery process.
2. The client may decline to proceed with certain techniques that the Counsellor/Trauma Debriefer may suggest.
3. The client may stop attending sessions at any time and may return to their sessions at any time.
4. The Counsellor/Trauma Debriefer reserves the right to dismiss the client from the sessions.
5. The client has the right to review their records from the Counsellor/Trauma Debriefer.

Right to Confidentiality

6. Within the limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance with the principles of a counsellor-client relationship
7. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client or a valid court order.
8. The client can raise any concerns and speak with the Counsellor/Trauma Debriefer immediately about any concerns, provided that the Counsellor/Trauma Debriefer is available to discuss matters with the client.
9. The Counsellor/Trauma Debriefer may offer the client the option of referring them to a Specialist if there is a situation that is out of the Scope of Practice for Kylie Grové Counselling.

Acknowledgements

By signing this form, I acknowledge and consent to the following:

I am legally allowed to sign this document and I hereby consent to counselling/trauma debriefing.

I have read and agree to the terms of Informed Consent for a Minor to be Counselled.

All the details submitted herein are true and accurate to the best of my knowledge.

I understand and accept the rights as defined in the "Client's Rights" and "Rights to Confidentiality”

I accept and agree to signing this agreement digitally has the same validity and effect as signing with a wet signature on paper.

I consent to have this website store my submitted information for purpose of my application.

Signature

Sign Here

REGISTRATION STEPS FOR NEW CLIENTS

Quick & Easy Registration

The Intake Form

Informed Consent Agreement

Choose Your Date

Complete the Intake & Consent Form

Intake Form

Applicant Personal Information

Parent / Legal Guardian

Marital Status of Applicant

Details of Dependants

Counselling History

Current Situation

Medical Information

Common Problems / Symptoms Checklist

Consent Form

Client Rights

Right to Confidentiality

Acknowledgements

Book Your Appointment

REGISTRATION STEPS FOR NEW CLIENTS

Quick & Easy Registration

The Intake Form

Informed Consent Agreement

Choose Your Date

Complete the Intake & Consent Form

Intake Form

Applicant Personal Information

Parent / Legal Guardian

Marital Status of Applicant

Details of Dependants

Counselling History

Current Situation

Medical Information

Common Problems / Symptoms Checklist

Consent Form

Client Rights

Right to Confidentiality

Acknowledgements

Book Your Appointment

Important Message!

Important
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