Counselling Consultation and Consent Form

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Client Details

Full Name *

Date of Birth *

Contact Number *

Email *

Address *

Postcode *

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Relationship to you *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies? *

Please list: *

Do you have any medical conditions? *

Please list: *

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Lifestyle

Do you smoke cigarettes?

How many cigarettes would you smoke in a typical day?

Do you drink alcohol?

How often do you drink alcohol?

Do you consume caffeine on a typical day?

i.e. coffee or energy drinks

How much caffeine do you drink in a typical day?

Do you use recreational drugs?

Would you say you are dependent on drugs, alcohol or tobacco?

Please rate your physical health:

Please rate your mental health:

Please rate the quality of your sleep:

On average, how many hours of sleep do you get per night?

What is your occupation?

Wellbeing

Please tell us why you are seeking counselling right now?

Have you been to your GP regarding this issue?

Have you ever had psychiatric treatment or been prescribed medication for psychological reasons e.g. depression, eating difficulties, alcohol or drug use?

Please give details:

Have you ever had any counselling therapy before?

When did you last receive therapy? Was it beneficial for you?

What emotional support is available to you?

What do you like about your life?

What would you like to improve about your life?

What are your greatest concerns right now?

Do you have any other notes you wish to make?

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Informed Consent

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.

WHEN DISCLOSURE IS REQUIRED, OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client’s family members communicate that the client presents a danger to others.

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the person whose name you have provided.

LEGAL PROCESSES: Sometimes clients become involved in a legal issue while they are in therapy or after therapy has been completed. Sometimes clients (or the opposing solicitor) want the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure regarding many matters, clients’ records are generally confidential and private in nature. Clients should know that serious consequences can result from disclosing therapy records to the legal system. Such disclosures may negatively affect the outcome of custody disputes or other legal matters and may negatively affect the therapeutic relationship. If you or the opposing solicitor are considering requesting the clinic’s disclosure of the records, I will do my best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own therapy records anytime. (See also relevant section above: “WHEN DISCLOSURE IS REQUIRED, OR MAY BE REQUIRED BY LAW”)

CONSULTATION: I may consult with other professionals regarding my clients; however, each client’s identity remains completely anonymous and confidentiality is fully maintained.

RECORDS AND YOUR RIGHT TO REVIEW THEM: Please note that clinically relevant information from emails and texts are part of the clinical records. Unless otherwise agreed to be necessary, I retain clinical records only as long as is necessary. If you have concerns regarding the treatment records, please discuss them with me. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case, I will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, I will release information to any agency/person you specify unless I assess that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, I will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, I will discuss with you my working understanding of the problem, treatment plan, therapeutic objectives, and my view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

TERMINATION: You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, I will provide you with names of other qualified professionals whose services you might prefer.

I have read the Informed Consent form in full. I understand the terms and agree to comply with them.

Client Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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