The Counselling Intake Form Template – Australia is offered in multiple formats, including PDF, Word, and Google Docs. These versions are designed to be both editable and printable, ensuring they cater to your specific requirements effortlessly.
Counselling Intake Form Template – Australia Editable | PrintableSample
1. Client Information 2. Emergency Contact 3. Reason for Seeking Counseling 4. History of Counseling 5. Current Concerns 6. Medical History 7. Goals for Counseling 8. Consent to Treatment 9. Client Signature and Date 10. Therapist Notes
PDF
WORD
Examples
Full Name: [Client’s Name]
Date of Birth: [DD/MM/YYYY]
Address: [Client’s Address]
Phone Number: [Client’s Phone]
Email Address: [Client’s Email]
Name: [Emergency Contact Name]
Relation: [Relation to Client]
Phone Number: [Emergency Contact Phone]
How did you hear about us? [Referral Source Details]
Do you have any medical conditions? [Yes/No] – If yes, please specify: [Details]
What are your goals for counselling? [Objectives/Goals]
Please describe the issues you are currently facing: [Details]
I consent to the collection and use of my personal information for counselling purposes as per the privacy policy. [Signature/Date]
Name: [Client’s Full Name]
Age: [Client’s Age]
Gender: [Client’s Gender]
Preferred Pronouns: [Pronouns]
Phone: [Client’s Phone]
Email: [Client’s Email]
Address: [Client’s Address]
Occupation: [Client’s Occupation]
Educational Background: [Client’s Education]
Have you previously received counselling? [Yes/No]
If yes, when and for what reasons? [Details]
What would you like to achieve through counselling? [Details]
Please share any other relevant information: [Details]
I understand and agree to the counselling terms and conditions. [Signature/Date]
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