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Client Intake Form

This form allows you to choose your preferred expert and share a few details about your concerns or goals. Once submitted, the selected expert will review your information and contact you by email to schedule a free 20-minute consultation about our services and Cognitive Pattern Reprogramming.

Personal Details

Health Information

1. Are you currently under the care of a healthcare professional?

If Yes, please specify:

2. Have you been diagnosed with a serious mental illness?

If Yes, please provide details:

3. Are you on any medications?

If Yes, list medication names:

4. Do you smoke?

5. Do you drink alcohol?

If Yes, how many drinks per day?

Mental Health History

*Have you ever suffered from any of the following? (Tick all that apply):

Other (Please specify):

Current Concerns

*Do you experience any of the following? (Tick all that apply):

Other (Please specify):

Additional Needs

1. Do you have any concerns about your safety?

If Yes, please provide details:

2. Do you have any special needs or accessibility requirements?

If Yes, please provide details:

Insurance Information

1. Are you a member of a health fund?

Please Note: Rebates can vary, and changes in policy can occur at any time.
Please check your situation with your health fund provider.

Preferred Expert

Preferred Days & Time

Confidentiality & Privacy Statement

Your privacy is important to us. All information shared during sessions is confidential and protected. However, there are exceptions, as Mandatory Reporters if we believe there is risk of harm to yourself or others, abuse of a minor or disclosure of involvement in a major crime as mandatory reporters, we are required to report it to the relevant authorities. Additionally, it is possible that we could be subpoenaed by a Court of Law to provide your records and under that circumstance we are obliged to comply with those orders

Acknowledgment and Consent Signature

I confirm that the information provided in this form is accurate to the best of my knowledge and I give my informed Consent.

*Sign Date:

*Signature:

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