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Personal Information Form

Personal Information Form

This information is private and confidential.

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Please take your time to fill out this form (one for each Client) and understand our Confidentiality, Privacy and Cancellation Policies.

Personal Details

Medical History

Confidentiality, Privacy and Cancellation Policies


Information regarding your attendance to counselling sessions will generally not be disclosed without your consent. With regards to couple counselling, any communication between the counsellor and the representative of a couple may be communicated openly with the other partner at the counsellor's discretion. You should also be aware that information relevant to your care and well-being may be shared with my supervisor, so that we can work together to provide you both with the best possible service. In accordance with professional responsibilities and/or legislation, I may need to disclose details to other persons in the following circumstances:

• I have a reasonable belief that there is a risk to your health or safety, or that of another person.

• There is a legal requirement to do so.

• It is necessary to obtain legal advice.

In some of these circumstances, it may not be possible or practicable to seek your consent. However, every effort will be made to consult with you in the first instance.

Privacy and Record Keeping

Personal information gathered from you will be used for the primary purpose of your care.

If you do not provide the information requested, I may be unable to provide you with services or respond to your requests for additional support or referrals.

I maintain individual and/or couple files. This will contain records of any contact, key discussion points, outcomes and other relevant information provided during the counselling sessions with you.

All files are stored in a secure and safe location. Client files are retained for a minimum period of 7 years after completion.

Cancellation and Payment

In our commitment to provide the highest possible outcomes to all our clients, late arrival may result in a shortened session time to accommodate appointments following you. Full payment for your session will be required.

If for any reason you cannot keep your appointment, please advise us immediately (0402 145 339). Cancellations received with less than 24 hours' notice will be charged at the standard rate.

These policies have been adopted to ensure that the professionalism and ethics of our clinic are respected, and to ensure your session is a productive and beneficial experience.

Please note payment for service is required on the day of service. Cash, EFTPOS or Credit Card or previously cleared bank transfer are acceptable.

If you have any questions about our policies, please contact us at:
Open Heart Couselling Flower Back Ground Left