Intake – Holistic Counselling Form – Essential Healthcare Australia

Appointment type Full Name Client Age Group

Appointment Date Mobile Contact

Appointment Time Email

Client Personal Details

Street Address State Date of Birth

Suburb Post Code Gender

Occupation

Medical Clinic Details

Doctor / GP Emergency Contact

Previous GP Appt: Emergency Phone

Religion / Cultural Needs

Healthcare Provider Other Healthcare Provider Healthcare Provider Previous appt

LIFESTYLE Factors

Sleep Waking times ampm12-11-22-33-44-55-66-77-88-99-1010-1111-12

Your Relationships

Relationship Status Children

Family Status - Loving Family Status - Strained / Estranged Family Status - Other

Past Experience

Your Health - Medical and Family History

Your Health - Mental Health

Diagnosed Medical Condition

Date of Diagnosis

Immediate Family Medical Condition(s)

Paternal Family Medical Condition(s)

Maternal Family Medical Condition(s)

Diagnosed Mental Health Condition

Date of Diagnosis

Mental Health Disorders
General Symptoms
Past Experience

YOUR MEDICINES

Orthodox / Pharmaceutical Medicines

OTC Medicines

Social Drugs

Traditional / Herbal Medicines

Antibiotic Medicines

TREATMENT OBJECTIVES

Current Health Concern(s)

Health Goals

CLIENT Informed CONSENT

I give consent / agree that:
The consultation is designed to gather information for clinical purpose to formulate customised treatment plans aimed to achieve desired therapeutic outcomes
My health information is recorded in a medical file and will not be released to others unless so directed by myself or if law requires
Services provided to me are under the instructions of the treating Health Practitioner My health information may be shared and discussed between other healthcare providers for medical support
My intake form is completed prior to consultation and all information is honest, accurate, current and true
Details of any/all medical condition(s) and medical history, including any changes in my personal or health details, are fully disclosed.
Results may not always be guaranteed
I have read / or will read the information regarding consultation, assessment and treatment, accessible under the "consultation" menu on EHA's website, to keep me informed of my consultation, treatment, therapeutic objectives and outcome goals
In the event of emergency or other, I consent to the release of my medical information to my contact support person as listed above.

By signing this form, I give my consent to a Holistic Mental Health Counselling Consultation and Customised Treatment Plan

Client Signature Guardian Signature (If applicable)