New Client Intake & Consent

Please complete this form before your first session. It gathers the information Alison needs and includes the Counselling Agreement and Informed Consent for you to sign digitally.

Your answers are not saved on this website. When you submit, the completed form is emailed directly to Alison and a copy is emailed to you.

Step 1 of 4 — Your details25%

Full name *Preferred nameDate of birth *Occupation

Address

Mobile phone *Email *Home phoneWork phone

Do you identify as Aboriginal, South Sea Islander or Torres Strait Islander?Languages spoken at homePrivate health insurance (optional)Membership number (optional)

Participating health funds: HCF; Medibank & AHM; Bupa; Australian Regional Health Group (ARHG) funds — including Police Health, HBF, GMHBA, Westfund, Teachers Health, Doctors' Health Fund and TUH Health Fund.