Fill out the Necessary forms to Begin Your Journey with us.

Forms

First name*

Last name*

Date of Birth*

Marital Status*

Employment Status*

Email address**

Phone Number**

Street address*

City*

State/Region*

Emergency Contact

Health & Medical Details

Diagnosed/ Suspected Health Conditions ( Including Mental Health)

Previous Experience of Counselling/Psychotherapy

Risk Assessment - Are you experiencing current thoughts of suicide or self-harm?*

Yes

Are you experiencing risk of Domestic/Family Violence?*

Yes

Other Information* Reason for seeking Counselling*

Anything else you would like me to know about you?

Please review before submitting

Privacy Policy: During consultations, personal and health-related information is collected for administrative and professional purposes by Abundant Living Counselling. We are required to retain this information and maintain confidentiality as far as possible. In some circumstances, may be required or entitled to disclose personal information obtained. Please review the Privacy and Confidentiality Agreement on the website:

Fees and Cancellations:

Declaration: I have read and understood the above information and the privacy policy listed on the Abundant Living Counselling & Coaching Services website. I consent to Abundant Living Counselling & Coaching Services providing a counselling service to me listed above, based on that information, collecting personal information about me. I consent to Abundant Living Counselling & Coaching Services using and disclosing information as deemed appropriate and agree to the terms and conditions:

I agree with the Terms & Conditions above.*

The first session is one hour, and following sessions are 50 minutes. Arriving more than 15 minutes late will be considered a no-show and the full fee will apply.

https://abundantlivingproject.com/privacy-and-confidentiality-agreement

Full payment is required at the end of each session via debit card or bank transfer. Cancellations made within 24 hours of the appointment will be charged the full session fee.

I declare that the information provided is true and correct.

Fill out the Necessary forms to Begin Your Journey with us.

Empower