Allwayspresence
Allwayspresence – Client Intake Form completed in first session
1. Personal Information
Full Name: ___________________________________
Preferred Name: _______________________________
Date of Birth: ____ / ____ / ______
Gender: ______________________________________
Address: _____________________________________
Phone Number: _________________________________
Email: _______________________________________
Emergency Contact Name: _______________________
Relationship: _________________________________
Emergency Contact Phone: ______________________
2. Referral Information
Have you previously received counselling or therapy?
☐ Yes
☐ No
If yes, when and for what concerns?
3. Presenting Concerns
What has brought you to counselling at this time?
How long have you been experiencing these concerns?
☐ Recent (last few weeks)
☐ Several months
☐ More than a year
☐ Many years
4. Mental & Emotional Wellbeing
Please indicate if you are currently experiencing any of the following:
☐ Anxiety
☐ Depression / Low mood
☐ Grief or loss
☐ Stress or burnout
☐ Relationship difficulties
☐ Trauma or past abuse
☐ Anger difficulties
☐ Sleep problems
☐ Life transition
☐ Work or study issues
☐ Other: _____________________________________
5. Risk & Safety Screening
Have you recently experienced thoughts of harming yourself?
☐ No
☐ Occasionally
☐ Frequently
Have you ever attempted suicide?
☐ Yes
☐ No
If yes, please provide details if comfortable:
Do you feel safe in your current living situation?
☐ Yes
☐ No
☐ Unsure
6. Physical Health
Do you have any significant medical conditions?
☐ Yes
☐ No
If yes, please specify:
Are you currently taking any medication?
☐ Yes
☐ No
If yes, please list:
7. Current Supports
Do you currently have support from:
Partner / spouse: ☐ Yes ☐ No
Family: ☐ Yes ☐ No
Friends: ☐ Yes ☐ No
Community / faith group: ☐ Yes ☐ No
Other supports: __________________________________
8. Lifestyle & Daily Life
Employment status:
☐ Full-time
☐ Part-time
☐ Self-employed
☐ Unemployed
☐ Retired
☐ Student
Occupation: ___________________________________
Do you use alcohol or substances?
☐ No
☐ Occasionally
☐ Regularly
10. Consent & Confidentiality
Counselling is a confidential service. However, confidentiality may be limited where:
• There is risk of harm to yourself or others
• There are legal requirements (e.g., mandatory reporting)
• Records are subpoenaed by a court
Your counsellor will discuss these limits with you.
I understand the nature of counselling and consent to participate.
Client Name: __________________________________
Signature: ____________________________________
Date: ____ / ____ / ______
11. Office Use
Client ID: ___________________________________
Date of First Appointment: _____________________
Counsellor: __________________________________
__________________________________________________________________________________
Welcome
Counselling provides a confidential and supportive space where you can speak openly about your experiences, concerns, and hopes. The counselling process is collaborative and aims to support wellbeing, insight, and personal growth.
Nature of Counselling
Counselling involves conversation, reflection, and exploration of thoughts, feelings, and experiences. While many people find counselling beneficial, outcomes cannot be guaranteed.
You are free to ask questions, decline topics, or discontinue counselling at any time.
Confidentiality
All personal information shared in counselling will remain confidential except where disclosure is required by law or where there is serious concern for safety.
Confidentiality may be limited if:
• There is risk of serious harm to yourself
• There is risk of harm to another person
• There is disclosure of abuse of a child or vulnerable person
• Records are subpoenaed by a court of law
Where possible, these situations will be discussed with you.
Records
Brief notes may be kept supporting continuity of care and professional practice. These records are stored securely and treated confidentially.
Your Rights
You have the right to:
• Ask questions about the counselling process
• Access respectful and professional support
• Withdraw from counselling at any time
• Request referral to another practitioner
Emergencies
If you are experiencing an emergency or require immediate crisis support, please contact:
• Lifeline Australia – 13 11 14
• Emergency Services – 000
Client Agreement
I have read and understood the information provided in this intake pack and consent to participate in counselling.
Name: __________________________________
Signature: _______________________________
Date: ____ / ____ / ______
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