Intake Form
please compelete all fields
First Name*
Last name*
Birthday*
Day
Month
Year
Phone*
Email*
Address*
Name of Emergency Contact*
Relationship to emergency contact:*
Phone number of emergency contact:*
Consent to contact emergency contact in an emergency:
Yes
No
Other
Marital Status:*
Married
Divorced
Single
Widowed
Separated
Other
Occupation:*
Employment Status (Full-time, Part-time, Casual etc)*
Children*
Yes
No
Other
If yes, how many children and do they live with you?*
Have you previously attended therapy or counselling?
Yes
No
Other
If so, what therapy/counselling was it, and what aspects did you find helpful or unhelpful?*
Is your GP involved in your Mental Health care? If so, please provide details (they will not be contacted without your consent)*
Yes
No
Other
Any other health care provider involved in your Mental Health Care? If so, please providedetails (they will not be contacted without your consent)*
Yes
No
Other
Relevant Mental Health history?*
Taking medication? If so, what are you currently taking?*
Please check any conditions or diagnosis you have or have had in the past:
Anxiety
Depression
Bipolar Disorder
PTSD
OCD
ADHD
ASD
Eating Disorder
Substance Abuse
Personality Disorder
Chronic Pain Conditions
Autoimmune Conditions
Sleep Disorder
Suicidal Ideation
Other
Please check any symptoms you are currently experiencing:
Mood Swings
Sleep Problems
Panic Attacks
Social Isolation
Irritability or Anger
Suicidal Thoughts
Self-Harm Urges
Difficulty Concentrating
Racing Thoughts
Other
Please provide any other relevant information:
By submitting this form, you confirm you’ve read, understood and agree to Terra SoulTherapies’ Consent and Confidentiality Policy. You acknowledge your right to discuss orwithdraw consent at any time, except where required by law (as per AHPRA & PACFA)*
Yes
No
Other
Do you consent to Terra Soul Therapies contacting your GP or other healthcare providers tosupport your care, only with your prior permission and for care continuity purposes? Consentwill always be sought before any contact is made.*
Yes
No
Other
Payment Policy: Payment is required in advance of each session to confirm your booking.*
Yes, I Agree
No, I do not Agree
Cancellation Policy: Please provide at least 24 hours’notice to cancel or reschedule. Sessionscancelled within 24 hours require full payment, except in genuine or unforeseencircumstances.*
Yes, I Agree
No, I do not Agree
Thank you! Your submission has been received!
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