Client Intake Form

Client Intake Form (Step 1 of 2) | Heart Wired Therapy Skip to form

Step 1 of 2 · Intake

Please share your details below before our first session. Fields marked * are required. When you are done, continue to the consent agreement.

Thank you for choosing Heart Wired Therapy. This is a space to pause, reflect, and reconnect with yourself. To help me understand how best to support you, please complete the information below before our first session. There are no right or wrong answers, so share only what you feel comfortable sharing, and we can explore anything further together in session.

Your privacy matters. The information you provide is collected and stored in line with my Privacy Policy and the Australian Privacy Principles in the Privacy Act 1988 (Cth) and the Health Records and Information Privacy Act 2002 (NSW). It is used only to provide you with safe, informed and relevant support.

Personal details

Full name *

Name on ID (if different)

Date of birth

Email address *

Mobile phone

Home address & postcode

Preferred contact method

Living situation

Who do you currently live with? (names, ages and relationship to you, optional)

Health & wellbeing information

Please note any physical health issues you consider relevant to our work together

Please note any diagnosed mental health conditions (and whether you consider them accurate)

Any current medications relevant to our work (optional)

Do you have any accessibility requirements or preferences (e.g. communication, sensory, scheduling)?

GP name

GP medical clinic

GP contact details

Are you currently working with any other health care practitioner or service (e.g. physiotherapist, chiropractor, dietician/nutritionist, naturopath, other)? If so, please provide their name/business name

Emergency contact

Name

Relationship to you

Phone

Engaging in counselling

Have you previously consulted with any of the following? (tick what applies)

Please provide the name of the therapist/business name

If yes, what did you find helpful or unhelpful about those experiences?

What has prompted you to reach out for support now?

What would you like to get out of counselling?

Is there anything else you would like me to know in order to best support you?

How did you hear about Heart Wired Therapy? (optional)

If someone other than you is responsible for payment, please give their name and contact details

Your acknowledgement

Please be assured that your privacy with regard to the use and storage of this information will be respected in line with my Privacy Policy and the Australian Privacy Principles stated in the Privacy Act 1988 (Cth). The details above are accurate to the best of my knowledge.

Signed (type full name as your electronic signature)

Date

Thank you for completing this form. I look forward to working alongside you.