Welcome

This form helps me get to know you before our first session. Take your time — there's no rush. If anything feels too much right now, you can skip it and we'll talk in person.

About You

First Name *

Last Name *

Date of Birth

Pronouns

Gender Identity

Male

Female

Non-binary

Transgender

Gender diverse

Prefer not to say

Sexual Orientation

Straight

Gay

Lesbian

Bisexual

Asexual

Pansexual

Queer

Prefer not to say

Mobile *

Email *

Relationship Status

Occupation

Contact & Referral

Emergency contact details and how you found the practice.

Emergency Contact

Name

Relationship

Phone

GP Details

Having your GP's details helps with duty of care. This is optional — you can share it later if you prefer.

GP Name

GP Phone

How Did You Find Us?

Website

Google search

MHFA course

GP referral

Word of mouth

Social media

WorkSafe

Other

Service Type

What service are you seeking?

Individual counselling

Couples counselling

Professional supervision

WorkSafe counselling

WorkSafe Details

If you're accessing services under a WorkSafe Victoria claim, sessions are billed directly to WorkSafe at no cost to you. I just need a few details to get started.

Claim Number

Date of Injury

Employer Name

WorkSafe Agent

Private Health Fund

Yes

No

Which Health Fund?

You may be eligible for a rebate through your extras cover. Check with your fund about eligibility — mention that I hold PACFA Clinical registration. I can issue receipts suitable for claims upon request.

Communication Preferences

You may send me SMS reminders You may send me emails You may leave me a voicemail

What Brings You Here

Share as much or as little as you're comfortable with. We'll explore everything in our first session together.

What brings you to counselling at this time?

Have you been in therapy or counselling before?

Yes

No

Brief details (optional)

Fees & Payment

Individual counselling$160 per session

Couples counselling$240 per session

Professional supervision$160 per session

WorkSafe counsellingBilled to WorkSafe

PaymentDue at session

Payment methods: Credit card, debit card, or bank transfer.
Cancellation: A minimum of 24 hours notice is required to cancel or reschedule. Late cancellations and missed appointments may be charged at the full session fee. Emergencies are handled with discretion.

Consent

Signature (type your full name)

Date

✓

Thank You

Your intake form has been received. Paul will review it before your first session.

If you have any questions before then, please don't hesitate to get in touch.

Phone0405 023 777

Emailpaul@counsellingconcern.au

Websitecounsellingconcern.au

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