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Intake Form

Listening Counselling

Personal Details

Title
Gender/ Pronouns (optional)
Birthday
Day
Month
Year

Emergency Contact

GP/ Medical Contact

Referral Information (if applicable)

Terms and Conditions

Contact permission: I give permission to be contacted via email, SMS, or phone for appointment reminders, updates, and other non-urgent communication outside of sessions.

Informed Consent: I understand that counselling may involve discussing sensitive personal matters; that I may choose not to answer any question/s; and that I can end counselling at any time without penalty; and that outcomes cannot be guaranteed as they depend on my engagement and circumstances.

Confidentiality & Its Limits: (required by APS Code of Ethics, Privacy Act 1988). I understand that information I share will remain confidential except in the following situations: 1. My counsellor is required by law to report risk of serious harm to myself or others (mandatory reporting laws, Criminal Code Act 1899 Qld). 2. My counsellor must comply with a court order or legal requirement (APP 6.2(b)). 3. My counsellor is under professional supervision, in which case identifying details will not be shared. 4. My counsellor works with an assistant who may access my records to assist with case management.

Record Keeping: (APP 11, Health Records): I understand that my counselling records will be securely stored for a minimum of 7 years after my last session (or until age 25 if I am under 18 at the time of service).

Telehealth Service: I understand that telehealth sessions may differ from in-person sessions and may involve technical limitations; that if a session cannot proceed due to technical issues, alternative arrangements will be made (such as phone calls); that reasonable steps will be taken to protect my privacy, although no technology platform is 100% secure; that I will participate from a private location where I cannot be overheard; and that recording of telehealth sessions is not permitted. Telehealth will be conducted over video calls such as Zoom or other appropriate video conferencing avenues. I understand that telehealth is not suitable for all situations, including emergencies, and I agree to provide my current physical location at the start of each session in case emergency services need to be contacted.

Cancellation & Rescheduling Policy: I understand that cancellations made less than 24 hours before the appointment will incur full fees and repeated late cancellations or no-shows may result in the termination of services.

Session Boundaries: I understand that sessions will start and end at the scheduled time. My counsellor and I will not engage in any relationship outside the professional context. My counsellor may not be immediately available outside of scheduled appointment.

Termination of services: I understand that my counsellor may also terminate services if counselling is no longer appropriate for my needs, or I breach agreed boundaries or payment terms.

Types of Records Maintained: Session notes and summaries; assessment results and treatment plans; correspondence related to counselling as well as consent forms and agreements.

Storage and Security of Records: I understand that my physical records will be stored securely in locked filing cabinets, and electronic records will be password-protected.

Third-party attendance: I give consent for third-party attendees of my choice to be present, including acquaintances, friends, partners, family, children or support workers. I understand that these attendees will hear personal and potentially sensitive information and that confidentiality cannot be guaranteed once information leaves the session. I understand that all attendees will be asked to respect my privacy and not share session information with others, except where required by law. My counsellor may refuse third-party attendance if it is assessed as not being in my best therapeutic interests.

Privacy Policy: I understand that my personal and sensitive information is collected for the purpose of providing counselling services and will be stored securely and only accessed by authorised personnel. I acknowledge that, subject to the provisions of the Australian Privacy Principles 12 and 13, I retain a contingent entitlement to submit a formally constituted request for both the retrieval and the rectification of any personal information pertaining to me that is held by this practice, such request to be processed in accordance with applicable procedural and statutory requirements. I understand that access may be limited in cases where disclosure could cause serious harm or where prohibited by law.

I acknowledge awareness that I may initiate, in the first instance, a grievance in relation to the handling of my personal information directly with this practice, and, contingent upon the exhaustion or unsatisfactory outcome of such internal complaint resolution processes, may subsequently escalate said grievance to the Office of the Australian Information Commissioner, in accordance with legislatively prescribed mechanisms.

Confidentiality for children and adolescents: What the child/adolescent shares in counselling is private and will not be disclosed to parents/guardians without their consent, unless: 1. There is a risk of harm to the child/adolescent or others. 2. There is suspected abuse or neglect. 3. Disclosure is required by law or court order.

Limitation of Liability: The services provided by Listening Counselling are intended for therapeutic support and general well-being purposes only and are not a substitute for medical, psychiatric, or other professional advice, diagnosis, or treatment. While all reasonable care is taken in the provision of services, you acknowledge and agree that participation in counselling may involve personal emotional challenges, and outcomes cannot be guaranteed. To the fullest extent permitted by law, practitioners shall not be liable for any direct, indirect, incidental, or consequential loss, damage, or injury (whether physical, psychological, or otherwise) arising from your participation in counselling sessions, except to the extent caused by proven negligence. You are responsible for your own well-being during and after sessions, and you should seek appropriate emergency or crisis support if required.

Client Consent Statement

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Date
Day
Month
Year

Mental Health Form

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. The rating scale is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree or a good part of time 3 Applied to me very much or most of the time

1. I found it hard to wind down
0
1
2
3
2. I was aware of dryness of my mouth
0
1
2
3
3. I couldn’t seem to experience any positive feeling at all
0
1
2
3
4. I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion)
0
1
2
3
5. I found it difficult to work up the initiative to do things
0
1
2
3
6. I tended to over-react to situations
0
1
2
3
7. I experienced trembling (e.g. in the hands)
0
1
2
3
9. I was worried about situations in which I might panic and make a fool of myself
0
1
2
3
10. I felt that I had nothing to look forward to
0
1
2
3
11. I found myself getting agitated
0
1
2
3
12. I found it difficult to relax
0
1
2
3
13. I felt down-hearted and blue
0
1
2
3
14. I was intolerant of anything that kept me from getting on with what I was doing
0
1
2
3
15. I felt I was close to panic
0
1
2
3
16. I was unable to become enthusiastic about anything
0
1
2
3
17. I felt I wasn’t worth much as a person
0
1
2
3
18. I felt that I was rather touchy
0
1
2
3
19. I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat)
0
1
2
3
20. I felt scared without any good reason
0
1
2
3
21. I felt that life was meaningless
0
1
2
3

Parent/Guardian Agreement consent form (children 14 & under)

Listening Counselling

The parent/guardian provides informed consent: for counselling to occur. 1. Where the child/adolescent demonstrates sufficient maturity (mature minor capacity), their own consent will also be sought. 2. Counselling is voluntary, and consent can be withdrawn by either the parent/guardian or the child/adolescent at any time by notifying the counsellor. Confidentiality is not to be broken unless. 1. There is a risk of harm to the child/adolescent or others. 2. There is suspected abuse or neglect. 3. Disclosure is required by law or court order. 4. The counsellor will encourage open communication between the child/adolescent and their parent/guardian wherever possible.

Parental/Guardian Involvement: 1. Parents/guardians may be invited to join part of the session or attend separate meetings to support the counselling process 2. The counsellor’s primary professional duty is to the child/adolescent’s therapeutic needs. 3. Cancellations must follow the practice’s policy.

By signing this agreement I confirm: I have the legal authority to consent to counselling for the child/adolescent named above. 2. I understand the purpose, potential benefits, and possible risks of counselling. I understand and agree to the confidentiality terms outlined. 3. I accept that dissatisfaction with counselling outcomes does not, in itself, constitute wrongdoing or negligence. 4. I understand my child/adolescent’s right to privacy within the limits of the law.

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Date
Day
Month
Year

Release of Information (ROI) Form

Request for Release of Information (ROI) form to obtain records from their previous mental and health services for Listening Counselling I hereby authorise

To release to Listening Counselling all relevant clients' past records for the purpose of assisting in providing ongoing counselling and ensuring continuity of care. I understand I may withdraw this consent at any time, except where the information has already been provided

Date of Birth
Day
Month
Year
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Date
Day
Month
Year
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0449288904
info@listeningcounselling.com.au
69 Thomas Street, West End  4101
Brisbane, Queensland, Australia

Acknowledgement to Country

 

We acknowledge Aboriginal and Torres Strait Islander peoples as the First Peoples, the original and continuing custodians of the lands, waters, and skies on which we live, learn, and work. We honour their enduring connection to Country, culture, language, story, kinship, and Law. We recognise that sovereignty was never ceded. Because of this truth, we commit to walking alongside First Nations peoples—listening deeply, following their leadership, and taking guided action to challenge racism, disrupt injustice, and actively support the fight for Land Back, Treaty, truth-telling, and the full realisation of First Nations rights.

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LISTENING COUNSELLING

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