TLC INTAKE FORM

ALL ABOUT YOU

First Name *

Last Name *

Email *

Phone *

Can I text and call you on this number? *

Address *

City *

State *

Zip/Postal code *

Country *

Date of birth *

How did you hear about TLC? *

ALL ABOUT FAMILY

Do you have any children? *

Yes

It's complicated at the moment

Prefer not to say

ALL ABOUT HOW I CAN HELP

Have you seen a Coach or Therapist before? *

Yes

If yes, when? And how would you describe your experience?

Why did you book in to see us? *

Anything else going on right now? *

How severe is your situation? *

I am highly distressed

I am moderately distressed

I am minimally distressed

I am not distressed

Please list any current medications

EMERGENCY CONTACT

Emergency Contact Person's Name *

Relationship to you *

Emergency Contact Phone *

CLIENT CONSENT FORM

Therapy & Coaching Services

Providing a consulting service means that I will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the consultation. You do not have to provide us with all your personal information, but this may impact the service that we are able to provide.

Privacy

Any information is gathered as part of the consultation service and is seen only by myself. The information is retained in order to document what happens during sessions, and enables me to provide a relevant and informed service. At any stage you as a client are entitled to access the information kept on file about you. I may discuss with you the appropriate forms of access.

Confidentiality

Please be assured that all information provided in the process of consultation will strictly remain confidential and secure. Other than the special circumstances outlined below, no information may be released to others without the written consent from you . These special circumstances include the following: 1. Where a court orders the release of client information for legal purposes 2. Failing to disclose the information would place you or another person in serious or imminent risk. 3. Your prior approval has been obtained to provide a written letter or report to another other agency (eg: GP) or discuss the material with another person (eg: parent, employer) 4. If the disclosure is required by law.

Fees

The cost of consultation varies depending on your selected service. The agreed upon payment is due via thelifeconsultant.co website, invoice or in person. In special circumstances, discounts may be applied. The revised cost will be discussed and agreed upon prior to the first session and payment of the amended amount will be required before the session begins. All prices are in AUD. If you elect to pay by monthly instalments, payment must be received by the 1st of each month you are in the Program, over the first 3 months or dates as agreed upon. If you elect to pay in FULL, payment must be made via thelifeconsultant.co website, invoice or in person, prior to the first session.

Cancellation Policy

If, for some reason you need to cancel or postpone your appointment, please give at least 48 hours' notice. If less than 24 hours' notice is given or if you fail to attend with no prior notice, you will be charged 100% of the full session fee. All cancellations to be made via email to [email protected] Thank-you in advance for your respect and understanding.

Rescheduling Policy

Appointments made via the online booking service can be rescheduled by you with no penalty, provided this is done 48 hours in advance of the initially booked appointment. Once payment is made for a session, fees are 100% non-refundable, but session fees can be applied to an appointment at a later date.

Emergency & After Hours

The Life Consultant does not operate as an Emergency or After Hours service. If you are in an emergency situation, please contact your nearest hospital emergency department, and if needed access Lifeline, which operates a 24hr crisis counselling telephone service on 13 11 14 within Australia only.

I HAVE READ THE ABOVE INFORMATION CORRECTLY AND CAREFULLY AND UNDERSTAND : *

Information about me will be collected for the purposes of the consultation session

All fees to be paid in full prior to first consultation unless otherwise agreed

The cancellation policy

There are circumstances (outlined above) under which the confidentiality of the information I provide may be broken

The Life Consultant does not provide emergency or after hours coverage and I know where to go to receive help if required

I can withdraw from consultation at any time without prejudicing any future consultation requests

The Life Consultant can withdraw from consultation at any time with verbal notice

I have read and agree to ALL the TERMS & CONDITIONS above

Signature *

Clear