Client Service Form

 

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Contact Details

Gender

Address

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Preferred means of contact

Other Details

Are you currently receiving any other counselling or therapy services?

Health

How would you rate your current physical health
How would you rate your current sleeping habits
From the list below tick all that apply. Are you experiencing, or have you ever experienced any of the following:
Depression
Trauma / PTSD
Sexual Abuse
Emotional Abuse
Domestic / Family Violence
Anxiety
Panic Attacks / OCD / Phobias
Suicidal Thoughts / Attempts
Eating Disorder (please list)
Postpartum Depression / Anxiety
Infertility / Pregnancy Loss
Autism Spectrum Disorder (please list)
PMS / Menopause Concerns
Bipolar Disorder
Schizophrenia / Schizoaffective Disorder
Borderline / Other Personality Disorder
Substance Abuse / Addictions
Chronic Health Condition
Other
Are you currently experiencying any chronic pain?
Are you currently taking any medications for your physical or mental health?
Did you fill out this form on behalf of someone else? If yes, include your name, contact details and relationship to client:
Are you the authorised carer/guardian for the person who you are completing the form for?

Informed Consent

This section is to indicate if you give permission for us to inform your other medical practitioners/health provider of your involvement in Holistic Integrated Creative Art Therapy. This doesn't mean that clinical information is shared without your permission, but that we can contact them to let them know you are doing art therapy and later on an as needs basis - if necessary.
I do give / do not give my informed consent for the practitioner to contact my other treating practitioners.