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Client Intake Form

Body & Soul
Unite

Personal Information

Medical History

Have you received therapy or counselling before?
Have you ever been diagnosed with a medical condition or illness?
Have you had any operations?
Do you have any current physical issues, such as pain or other conditions?
Are you pregnant?

Medications or Supplements

List all of the medications and supplements you're currently taking including vitamins, herbs, minerals. 

Lifestyle

On average, how many litres of water do you drink per day?
How would you describe your average daily eating habits?
On average, how many hours do you sleep a night?
On average, how many days per week would you exercise?
Do you smoke cigarettes? If yes, on average how many per day?
Do you vape?
Do you have any addictions? If yes, please list below.

Family History

Do you have any children?
Do you have any siblings?
Do you have any cultural background other than Australian?

Family History of Illness and/or Addictions

Mental Health

Patient Consent Clause 

I require your consent to enable me to handle personal information about you and conduct your treatment. If you have any questions or concerns about this, please feel free to ask for a further explanation.

I understand that:

 

  • I am not obliged to provide any information requested of me but that my failure to do so might compromise the quality and outcome of the health care and treatment given to me. My health records are confidential and case notes taken during my consultation are de-identified and stored on a secure server that is not accessible outside of Body & Soul Unite. Under no circumstances will my private information be disseminated or otherwise shared, unless legally requested via subpoena or police warrant.

  • I am aware of my right to access the information collected about me, except in rare circumstances where information may be withheld, and I understand that I will be given an appropriate explanation in these circumstances.

  • I consent to the sharing of my information with other practitioners of Body & Soul Unite confidentially in circumstances where it is deemed necessary to ensure a high standard of care.

  • My private information will not be shared with any persons or practitioners outside of Body & Soul Unite without prior consent in writing.

  • I understand and accept that the treatment provided by Body & Soul Unite is not Guaranteed to heal/rehabilitate. There are no refunds provided once the consultation has commenced and the total fee for the chosen session is payable. I release any liability on-site or off-site while under Body & Soul Unite's care, direction or advice and release Body & Soul Unite from any liabilities such as overdose, death or injury incurred or claims to damages..

  • I acknowledge that I may be referred to another medical practitioner when my case exceeds the expertise or scope of practice of the practitioners within Body & Soul Unite to ensure duty of care.

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