ERC Intake Form

This form is designed to gather essential information about you and your needs, allowing us to better understand how we can support you on your emotional wellbeing journey. Rest assured that all information shared with us is handled with the utmost confidentiality and care. We look forward to the opportunity to work together towards your emotional wellness goals.

Client Intake Form

Date

YYYY

Name

First Name

Last Name

Address

Contact Number

(###)

###

####

Gender

Please state the gender that best describes you.

Pronouns

Please let us know what your pronouns are.

Date of birth

YYYY

Country of birth

Are you an Australian resident or citizen?

Yes

Have you used this service before? If so, Please state when

EMERGENCY CONTACT DETAILS

In case of emergency, who would we notify?

Name

First Name

Last Name

Relationship to you

Phone number

(###)

###

####

YOUR PHYSICAL HISTORY

Please fill out the following

Are you currently under a doctors care?

Yes

Name of GP

If you have one. Please write N/A if this does not apply to you.

Are you currently taking any medication(s)? If so, what kind and what is the reason for needing medication?

Please write N/A if this does not apply to you.

Any recent major illness, surgeries or chronic conditions? Please specify details.

Please write N/A if this does not apply to you.

YOUR MENTAL HEALTH HISTORY

Be as open and honest as possible

Have you ever been hospitalized for a mental illness? If yes, why were you admitted?

Have you ever been diagnosed with a mental illness? If yes, what was the diagnosis?

Do you have an addiction? If yes, what type of addiction?

Please answer either: YES, NO, UNCERTAIN with any additional information.

Do you take recreational drugs? If yes, what kind?

Do you drink? If yes, how often and in what quantity?

Have you made any past attempts of suicide? If yes, please provide details.

PAST COUNSELLING

Your history

Have you had counselling in the past?

If yes, please describe: When? Where? For how long? Why?

Why have you decided to come for counselling at ERC?

What would you like to experience that is different from what you are experiencing now?

What would you like to work on in counselling?

Confidentiality

Your counsellor keeps all notes secure in locked computer files. The information you share is kept confidential except in the following circumstances: Your counsellor may seek supervision with regard to your situation. In these cases, your personal details are not disclosed, and the supervisor holds the same level of confidentiality as your counsellor. If you share information about a serious crime that has been, or is going to be committed, your counsellor will need to notify the police. If your counsellor feels you are at risk of harm to yourself, or that you are a risk to another person, they will seek support for you through external means. If your counsellor learns that a child is at serious risk of harm or neglect, they will contact Community Services (as is required by law). In each of these cases, your counsellor will endeavor, where possible, to talk with you about the need to breach confidentiality. If you have any questions about this document, please ask your ERC counsellor.

I understand

REVIEW AND SIGN

Please read carefully

I agree and accept that I am the person signing this document. By Printing my name in the text fields below, I understand this is considered my signature on this document and I agree I have answered the questions truthfully.

Agree and understand

Your name

THIS IS CONSIDERED YOUR DIGITAL SIGNATURE.

First Name

Last Name

Crisis and Emergency

Please be aware that Emotion Revival Counselling is not an emergency or crisis service. In the event of a mental health-related emergency please contact one of the following:

Family Doctor/GP
Ring 000 for emergencies (police or ambulance)
Lifeline: 13 11 14
Beyond Blue: 1300 22 4636
Kids Helpline (ages 5-25): 1800 551 800
Suicide Callback Service: 1300 659 467
Mensline: 1300 78 9978
The National Sexual Assault, Family & Domestic Violence Counselling Line: 1800 737 732
Sexual Assault Crisis Line: 1800 806 292
Sane Australia: 1800 18 7263 (https://www.sane.org)