New Couple Form

New Couple

Note: Each partner to complete this form seperately

Complete this form if you are undertaking couples counselling. All your responses are confidential. If you do not feel comfortable answering a question, please just leave the response field blank.

Name

First Name

Last Name

Pronouns

Mobile Number

Address

Gender

Sexuality

Occupation

What is your partner's name?

How long have you been in a relationship for?

What is your relationship status (e.g. married, de facto)?

1. Have you previously received any type of mental health services? If so, when and for how long?

2. What was helpful and/or unhelpful?

3. Are you currently taking any prescription or psychiatric medication?

4. How would you rate your current physical health?

5. Are there any current specific health problems you are experiencing?

6. Are you currently experiencing overwhelming sadness, grief or depression? If so, please explain.

7. Do you experience panic attacks, phobias or anxiety? If so, please explain.

8. How often do you drink alcohol?

9. Do you engage in recreational drug use? If so, what and how often?

10. On a scale of 1 – 10 (1 being poor and 10 being exceptional), how would you rate your relationship?

11. Have you experienced emotional, physical or sexual abuse with your current partner? If yes, please explain.

12. What significant life changes or stressful events have you experienced recently?

13. Do you consider yourself to be spiritual or religious?

14. Is there anything else that would be helpful to share to your therapist?

15. What are your goals for counselling?

Please confirm you have read and understood the Consent Form below and that you agree to the conditions for the professional services provided by Coupled Counselling.

I understand and agree to the Consent Form

Consent Form

As a client of Coupled, there are a few things that are important for you to understand about:

1) Confidentiality & Privacy

2) Our Fees

3) Our Cancellation Policy

Confidentiality & Privacy

During your therapy sessions it’s likely that you will disclose highly personal information. We want you to know that we will respect confidentiality and manage your privacy in a responsible way.

All personal information gathered during your sessions will remain completely confidential unless:

1. We believe there is serious risk to life, health or safety

2. You have given us prior approval

3. It’s required by law or is subpoenaed by a court

For administrative purposes, we also manage your personal information so we can run our practice, including:

· Billing and invoicing

· Maintaining clinical records

· Discussing your case within the practice, so we can improve care to you

· Discussing your case anonymously with other practitioners/psychologists for the purpose of improving psychological practices and therapies for the benefit of men and women generally.

If you have any questions, requests or concerns about confidentiality or your personal information, please let us know.

Our Fees

Our counselling sessions typically run between 50 to 55 minutes. The cost of the session is $220, which is payable at the end of the session by credit card.

Private health care insurance rebates may be available. We can provide receipts for services so you can pursue reimbursement through your insurance company, if allowable.

Our Cancellation Policy

If for some reason you need to cancel or postpone your counselling session, please give us at least 24 hours notice. If you do not provide 24 hours notice, you are responsible for the full payment for the missed session.