Intake Form.

This intake form collects some basic contact information and presenting issues. Please be assured that all information you provide in this form will be treated with utmost confidentiality and will not be shared with any persons or organisations without your authorisation.

Terms and Conditions:

I. Code of Ethics: I adhere to the Code of Ethics as supplied by the Australian Counselling Association (ACA) and The Australian, New Zealand and Asian Creative Arts Therapies Association (ANZACATA).

II. Confidentiality: All communications and records pertaining to your care will be treated as confidential. No disclosure of information will be made without your expressed or implied permission, except where my art therapy service has a legal obligation to do so.

III. Professional Fees: Fees for a session are to be paid at the time of the booking.

IV. Cancellation Policy: Payments are non-refundable and the full fee will apply in the event of a cancellation. Appointments can be rescheduled in special circumstances, if given 24 h notice.

V. Sessions: Clients are advised to arrive on time, as late arrival means a shorter session time.

VI. Zero Tolerance: Verbal or physical abuse, aggressive, offensive, intimidatory, or disrespectful behaviour or language will not be tolerated. You will be asked to leave immediately.

Name

First Name

Last Name

Contact Phone

Address

Occupation

Date of Birth

Emergency Contact

Presenting issues

In order to better address your needs, please complete the following.

Medication

Specific concern

Medical / psychiatric history

Previous therapy / counselling

Other information

Please provide any other information that you think is relevant for me to know in order to work with you safely and effectively.

By submitting this form, I declare that I have read and understood all of the questions and the associated terms and conditions on this form. I further declare that I have answered all of the questions truthfully, and that I will inform Daniela Miszkinis Art Therapy of any changes.