What is your name?* First Last What is your email address?* What is your phone number?*What is your age?Do you have any past illness, injury or ailment?*NoYesAilment List*Please list them here.Are you currently on any medication?*NoYesMedication ListWhat medication are you taking and for what health issue?Do you use alcohol or recreational drugs?*NoYes*How often?RarelyMonthlyWeeklyDailyHave you previously been to counselling?*NoYesCounselling Before List*For what reason and how did you feel about the experience?Why do you want to receive counselling? Anxiety Depression Grief Stress Break up Panic Attacks Anger Self-esteem Confidence Other Why do you want to receive counselling otherPlease list:*How long have you been suffering from this issue?A few daysA few weeksA few monthsYearsMy whole lifeWhat do you hope for/expect from counselling?*Is there any other information you would like me to know?Consent* I have read and agree to the Better Counselling policy1. Cancellation and rescheduling Our online booking system allows you to effortlessly cancel reschedule to another time that better suits you. Clicking the link in your email will allow you to reschedule or cancel your booking. Cancellations or reschedules only be done up until 24 hours prior to your counselling session. After this time, the full fee may be forfeited. 2. Confidentiality Confidentiality is maintained for clients as far as possible but when a person or persons are at risk, confidentiality must be waived and the appropriate authorities or family members notified. Such situations include the following: 1. The client is at risk of serious self harm or of considering suicide, 2. Of harming another person or committing homicide, 3. Abuse of children is a mandatory reporting offence which I am required by law to report. Where confidentiality cannot be maintained your counsellor will take all possible steps to first inform/discuss their intention with you. 3. Recording. Standard protocol is that each session is recorded. This will allow your counsellor to review your session prior to your next appointment. The notes will also be used by your counsellor to refer back to, allowing us to provide you with a focused follow up session and midweek strategies. The recording allows us to offer you a customised program. If you wish to opt out of recording, please let the counsellor know at the start of your session. Opting out may reduce the quality of the between session support.