Client Intake Form - RCT

Please fill out the following form
before our first call.

Please note - personal information is shared at your discretion. Sharing as much as possible may assist in your sessions, and all forms submitted are stored securely and only viewed by your therapist or other persons you authorise, unless legally required to.

First Name

Last Name

Date of Birth

Address

Phone

Gender

Relationship status

Occupation

Hours per week

Referred by

EMERGENCY CONTACT Name

Relationship to you

Contact number

FAMILY HEALTH HISTORY Relation

Illness/Addiction

PERSONAL HISTORY Diagnosis

Details - When started, current/past & symptoms

Medications/Suppliments - Dose and frequency

Do you have any current physical issues? Pain or other condition?

Have you tried othr therapies? If so, please list below

LIFESTYLE

How many hours sleep do you average at night?

Do you have trouble falling asleep? Staying asleep?

Do you exersize? If you, what type of exersize do you do?

What do you do for fun?

How do yuexpress yourself creatively?

What do you feel are you main stressors currently?

Please provide any other information that may be relevant but hasn't been covered in regard to emotions.

ENVIRONMENT

What type of environment did you grow up in? What was your parents relationship like? How was school etc?

Are there any reoccuring patterns in your life? (If unsure, leav blank)

Please describe your goal/s for attending these sessions. How do you want to feel or what would you like to be able to acheive out of the program.

Patient Consent Clause and Teletherapy Waiver

We require your consent to enable us to handle personal information about you and conduct your treatment.

If you have any questions or concerns about this, please feel free to ask for a further explanation.

I understand that:

I am not obligated to provide any information requested of me but that my failure to do so might compromise the quality and outcome of the treatments given to me. My health records are confidential and case notes taken during my consultation are de-identified

and stored on a secure server that is not accessible outside of Enlightening Moods.

Under no circumstances will my private information be disseminated or otherwise shared, unless legally requested via subpoena or police warrant.

I am aware of my right to access the information collected about me, except in rare circumstances where information may be withheld, and I understand that I will be given an appropriate explanation in these circumstances.

I consent to the sharing of my information with other practitioners of Enlightening Moods in a

confidential manner in circumstances where it is deemed necessary to ensure a high standard of

care.

My private information will not be shared with any persons or practitioners outside of Enlightening Moods without my prior consent in writing.

I understand and accept that the treatment provided by Enlightening Moods is not Guaranteed to heal/rehabilitate and there are no refunds provided once the program/session has commenced and total fee for the chosen program is payable. I release any liability on-site or off-site while under Enlightening Moods’s care, direction or advice and release Enlightening Moods from any liabilities such as overdose, death or injury incurred or claims to damages.

I acknowledge that I may be referred to another medical practitioner when my case exceeds the

expertise or scope of practice of the practitioners within Enlightening Moods to ensure duty of care.

Teletherapy Waiver:

I, ___________________, hereby consent to engage in teletherapy with Enlightening Moods.

I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications.

I understand that teletherapy/coaching also involves the communication of my medical/mental information, both orally and visually. I understand that I have the following rights with respect to teletherapy:

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential.

I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of

In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that if

I accept that teletherapy does not provide emergency services. During our first session, my allocated therapist and I will discuss an emergency response plan. If I am experiencing an emergency situation, I understand that I can call 000 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.

I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.

I understand that while email may be used to communicate with

I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law. I have read, understood and agreed with the information provided above.

Cancellation Policy:

I agree that any missed or rescheduled sessions without at least 24 hours notice will be forfeited without refund.

I agree that my session/program may be refunded after first session if not satisfied with service. No refunds provided once 2nd or subsequent sessions commenced.

Full name

I confirm and consent that I have read and accepted the above conditions and the information provided on this form is true and correct.

Your Signature

Thanks for submitting!