ClientForm1520 - Sydney Counselling and Life Coaching

Name *

First

Last

Residential address

Your current residential address

Date of Birth *

Enter your date of birth e.g. 23/10/1985

Country of Birth. Please indicate if Aboriginal and/or Torres Strait Islander *

Enter your country of birth

Home telephone *

Enter your landline telephone number here. If no landline enter 1111 1111

Mobile telephone *

Enter your mobile telephone number here. If no mobile, enter 2222 2222

Email *

Is this consultation under a Mental Health Plan *

Is this consultation subject to any current or intended legal action *

Is this consultation subject to any WorkCover or other insurance claim *

In case of urgency, name of Special Other to contact

Enter name, contact number and address (if you wish) of a person to contact in case of urgency

Medical

Please select from the above choices. Please discuss with your counsellor.

Do you suffer from

Please select from the above choices. Please discuss with your counsellor

Are you on any medication

Please list medication/s you are currently taking

Are your taking any recreational drugs

E.g. Marijuana, Ice, etc.

GP or other health professional

In case of urgency, please provide your GP or other health professional details here.

Do you agree to share information

Sharing of information only to other health care professionals or as directed by you.

Other information

Other information you wish to bring to the counsellor’s attention

What you need to know