CLIENT INTAKE FORM

Personal Information & Contact Details

First Name *

Last Name *

Preferred Name

Mobile *

Other Phone Number

Email *

Address *

City *

State *

Post Code *

Date of Birth *

Gender

Nationality *

Marital Status

Religion

Children

Spirituality

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contacts Relationship To You *

Relationships

Rate your relationships

Family

Rate your relationship

Partner/Spouse

Rate your relationship

Friends

Rate your relationship

Community Involvement

Rate your relationship

For your safety, I must be aware of all medical conditions for which you have been diagnosed or have symptoms which could impact your health and wellbeing

Current medical or psychological treatments: *

Main reason for session(s): *

Are you having treatment for this already? If yes provide details *

Previous treatments/modalities used: *

Which of the following do you have symptoms of (please tick any which you relate to): *

Stress

Anxiety

Depression

Other

Confidentiality, Cancellations, and Consent

All information gathered, about you, is held confidentially. In the event of a health and safety emergency, or should the safety of others be compromised, your information may be shared with any relevant parties which can consist of medical practitioners, emergency services, legal authorities, and/or other specific party.

Cancellations:

In respect to our wait-listed clients(also to your therapist) there is a minimum of 24-hours' in notice period, to change or cancel an appointment. If less than 24-hours’ notice is given and your appointment time cannot be filled, a cancellation fee will apply as set out in our full terms & conditions. These are available on our website, or contact The Golden Couch support team for a copy: [email protected].

Consent:

I confirm the information I completed in this form is true and correct, to the best of my ability. I acknowledge and agree that: This is my decision to attend psychotherapy sessions; I have not been persuaded beyond my choice to attend and undergo these sessions; The terms and conditions have been explained to me and I understand and agree to them; and I am 18-years and over, or the parent/guardian of the client under 18-years of age.

Full Name *

Signature

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