New Client Intake Form

Please complete this form before your first session. Your information is kept strictly confidential.

🔒 Your Privacy Is Protected

All information is collected under the Australian Privacy Act 1988 and used solely to assist your counsellor in providing care. It is never shared with third parties without your consent.

1 Personal Details

Full Name *

Date of Birth

Phone Number *

Email Address *

2 Emergency Contact

Contact Name *

Contact Phone *

3 Session Preferences

How did you hear about us? *

Type of session *

4 Reason for Counselling

What brings you to counselling? *
[textarea* presenting-concern placeholder "Tell Ros what is on your mind..." 6x5]

Have you had counselling before?
No, this is my first timeYes, I have had counselling before

If yes, describe your previous experience (optional)
[textarea previous-experience placeholder "Type, duration, what was helpful or unhelpful..." 4x4]

5 Medical Background (optional)

GP / Doctor name

Current medications

6 Consent and Privacy

Submitted securely. Ros will confirm receipt within one business day.