Your intake form

This helps me get to know you before we meet. It takes about 10 minutes, and you can skip anything in step 4 you'd rather talk about in person.

Your answers are saved on this device as you go, so you can come back to it. Once you submit, they're stored securely and only Shiyanka can read them.

1About you
2Contact
3Your situation
4How you've been
5Agreements

About you Full name *

Relationship status

Who lives with you? Their name, relationship to you and age. Optional. Occupation Optional

Contact details Mobile * Email *

Is it OK to email you? *

Street address Optional Suburb and state Optional

Emergency contact

Name * Phone number * Their relationship to you *

Your situation

Which of these apply? Tap any that apply. Optional.

Are you coming through an Employee Assistance Program (EAP)?

What's bringing you to counselling? A few words is fine. Optional.

How you've been

Everything on this page is optional. Tap anything that's been true for you lately.

Behaviour

Feelings

Physical

Are you currently taking any medication?

What do you hope to get from counselling? Is there anything else you'd like me to know?

Agreements

Please read each one, tick to agree, and sign the confidentiality agreement and cancellation policy. You can open the full versions in a new tab.

Confidentiality

What you share is kept confidential as far as possible. It must be shared with the appropriate people if you're at risk of serious harm or suicide, if someone else is at risk of harm, or if a child is being abused, which I'm required by law to report. Notes can occasionally be subpoenaed by a court. Where possible, I'll talk with you first.

Read the confidentiality agreement I have read and agree to the confidentiality agreement *

Sign the confidentiality agreement *

Use your finger or mouse

Cancellation policy

Please give at least 48 hours' notice if you can't attend. Cancelling with less than 24 hours' notice incurs a fee of 50% of the session cost, and missed appointments are charged the full fee.

Read the cancellation policy I have read and agree to the cancellation policy *

Sign the cancellation policy *

Use your finger or mouse

Privacy policy

Your information is stored securely in Australia and only used to provide your counselling. It's never sold or shared, except where the law requires it.

Read the privacy policy I have read and agree to the privacy policy *

Type your full name *

Date:

In crisis or need help right now? Call 000 or Lifeline on 13 11 14.