Intake Form

First name

Last name

Email

Phone

Birthday

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Contact

Relationship to Emergency Contact

Phone Number of Emergency Contact

Consent to Contact Emergency Contact

Yes

No

Other

Gender, Pronouns and Identity. I respect each person’s right to live in a way that feels true for them. If you would like to share your gender identity, pronouns, or anything about your identity that feels important for me to know, please write it below

Gender identity

Anything else you would like me to know about your identity or how you’d like to be addressed

Marital Status

Occupation

Employment Status

Children

Yes

No

Other

If so, how many

If you have children, do they live with you?

Have you had counselling/therapy before?

If so, what type of therapy/counselling?

If so, what was helpful and what was not helpful

Is your GP involved in your mental health care?

If so, do you consent to your GP being contacted?

Any other health care provider involved in your mental health care?

If so, do you consent to them being contacted if required?

Relevant mental health history?

What brings you to therapy?

Please provide any other relevant information

By submitting this form, you confirm you’ve read, understood and agree to Terra Soul Therapies’ Consent and Confidentiality Policy. You acknowledge your right to discuss or withdraw consent at any time, except where required by law (as per AHPRA & PACFA)

Yes

No

Please confirm that you have reviewed the fees information and consent to payment of the applicable fees

Yes

No

Cancellation Policy: Please provide at least 24 hours’notice to cancel or reschedule. Sessions cancelled within 24 hours require full payment, except in genuine or unforeseen circumstances.*

Yes

No

Cath Sully

Cath Sully

Terra Soul Therapies

Terra Soul Therapies