Client Intake Form - Pci College (Page 2 of 2) in pdf

________________________________________________________________________________ ___

Children:

_______________________________________________________________________

Client referred by

Self [ ]

Other: _____________________________________________

Name of Doctor:

________________________________________________________________

Address:

_______________________________________________________________________

Phone No:

_________________________

Medical History: ____________________________

____________________________________________________________________________________

Medication {s} _______________________________________________________________________

____________________________________________________________________________________

Presenting issues:

__________________________________________________________________

____________________________________________________________________________________

Why now?

_________________________________________________________________________

Previous Therapy / Counselling

Yes [ ]

No [ ]

Client understands confidentiality is not guaranteed if there is a threat to life for self {client} or other, in the

case of any type of sexual, physical or emotional abuse involving minors.

Yes _________________

No_________________

Client agrees for sensitive information to be held on file

Yes_____

No_______

All sessions are for 50 minutes to 1 hour in duration.

Please attend for your Sessions on time, as time cannot be made up at the end of a session due to other Client

commitments. Client agrees to notify cancellation of any session at least 48 hours in advance, failure to do so

will result in full payment being due.

Yes_______

No_______

Fee agreed €_________

Signed:___________________________________

Date: ___________________

Trainee Counsellor Signature: ____________________________________

2011-12

Client Intake Form - Pci College Page 2