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Intake and Screening Form

Name *
Email *
Subject *
Telephone *
Pet's Name
Pet's Age
Type of Animal
Date of Loss (If Applicable)
Length of Relationship With Pet
Circumstances of loss (if applicable): e.g. accident, euthanasia, chronic illness, old age, aggressive, sudden illness etc. * *
If applicable, has your pet been given a diagnosis by a vet? If so, please provide some details here:
Do you have any special concerns you would like to address through this counselling?
If Other
Do you have any additional information you would like me to know?


Disclosure and Consent Form

When you seek support through Counselling there are some things you need to be aware of. The following will help you gain more out of your time spent together with me.

  • You may experience memories/events you feel have been dealt with, and you may find yourself experiencing a therapeutic intervention process that surprises you; this is normal.
  • You may experience yourself saying things within a session that take you by surprise; this is normal.
  • You may have experiences within a session that challenge you; this is normal.
  • Sometimes it can feel as if the session doesn’t work on the issue you came into the counselling space with; this is normal.
  • As your Counsellor, my role is to keep you safe within the session and to assist you to process whatever comes up.
  • Benefits of Counselling cannot be guaranteed because it is an interactive process that relies heavily on you, your responses and openness, and the issues in question. Every individual has different perceptions and expectations. Many people experience positive and constructive outcomes which vary according to the individual.
  • I cannot guarantee single session success, nor can I guarantee that only one session is needed for any specific issue, although this may be the experience of some clients.
  • The success of any session depends greatly on your willingness and desire to affect change, regardless of what may arise within a session.
  • Sometimes you will discover, after having a session, that you don’t want to change the presenting issue; this is normal.
  • I will do everything in my power to ensure your success; this may include changes in behaviours or feelings and may be different to what was expected.
  • I will not ‘make you change’ or do anything you do not want to do.
  • Expectations may not match the actual outcome of any session.
  • Counselling is not a replacement for medical treatment or psychiatric services.
  • Counselling does not seek to treat, prescribe, label or diagnose any condition.
  • I will inform you immediately if, in my judgement, you would be better served by another professional or an alternative/complementary means to reach your goals.
  • You are free to terminate any or all sessions at any time and I welcome feedback regardless of whether it is good, bad or indifferent as this helps me to reflect and work in other ways that may be of assistance to other people also.
  • You agree to participate in each session to the best of your ability.

Cancellation

I know sometimes life happens, so if you are unable to make it to your appointment, please provide 24-hour notice where possible as that may provide an opportunity for another person to fill your appointment time.

Confidentiality

All personal information relating to you will remain confidential and secure except when:

  1. It is subpoenaed by a court; or
  2. Failure to disclose the information would place you or another person at risk; or
  3. Your prior approval has been obtained.

Australian Government Privacy Legislation applies to information collected by me, your Counsellor.

Other

Filming or recording of sessions is not permitted unless approved prior by all parties involved.

Friend requests via social media of any means (personally) will be declined due to professional/ethical codes of conduct.

I have read the above and understand and give my full consent to the provision of counselling and support sessions from By My Side Counselling and give consent for my session to proceed on the basis described above.

Reach Out

Email *
Subject *
Name *
Message
Tagline - Delivering the NDIS in your community
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Monday – Friday
9:00 AM – 7:00 PM
Online and telephone support available by appointment.

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