ANANDA WELLNESS
CLIENT RECORD & CONSENT FORM
Rear 137, Station St. Fairfield. VIC 3078. Tel: (04) 21674093; ABN: 65972507258
Please Note: These forms are confidential and the information you provide will be used for therapy only.
Please read the terms of service below and then complete the form in as much detail as possible so that we are able to provide you with appropriate therapy.
TERMS OF SERVICE:
Your service fees or incentive will be agreed upon prior to the session
COUNSELLING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you/ you and a partner/ child and a trained therapist who has the desire and willingness to help you accomplish your individual goals. Counselling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counselling, there may be periods of increased anxiety or confusion. The outcome of counselling is often positive; however, the level of satisfaction for any individual is not predictable.
CONFIDENTIALITY: All interactions with Ananda Wellness Australia & Niveen Rajabdeen, including scheduling of or attendance at appointments, content of your sessions, progress in counselling, and your records are confidential.
EXCEPTIONS TO CONFIDENTIALITY: 1) If there is evidence of clear and imminent danger of harm to self and/or others, a therapist is legally required to report this information to the authorities responsible for ensuring safety. 2) Counsellors have a legal requirement to notify the relevant authorities should they learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age. 3) A court order, issued by a judge, may require the release of information contained in records and/or require a therapist to testify in a court hearing.
We appreciate prompt arrival for appointments. Please notify me by calling, emailing or texting me on the mobile (042 167 4093) if you will be late. Forty-eight hours’ notice of any cancellation is required, otherwise there is a $50 fee.