Form

Full Name*

Date of Birth*

Medicare Card Number (if available)

Email*

Home Address*

Phone Number*

Emergency Contact (Name, Relationship and Phone Number)*

Do you identify as Aboriginal/Torres Strait Islander?

Yes

Are you currently undergoing psychiatric treatment, counselling or therapy elsewhere? (Please provide details below).*

Do you have any health concerns we should be aware of? (Please provide details).*

Consent: Psychological treatment is a confidential process designed to help you address your concerns, implement changes, transform aspects of your life, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist who has the desire and willingness to help you accomplish your individual goals. Therapy involves sharing sensitive, personal, and private information that may at times be difficult. During the course of treatment, there may be periods of increased anxiety or confusion. The outcome of treatment is often positive; however, the level of satisfaction for any individual is not predictable. Your psychologist is available to support you throughout the counselling process.*

I have read and understood the above information and consent to initiate psychological intervention by Gustavo Gallo Bolzani.

Confidentiality: All interactions with Quiron Psychology, including scheduling of or attendance at appointments, content of your sessions, progress in treatment, and your records are confidential. You may request in writing that Quiron Psychology release specific information about your treatment to persons you designate. The only exceptions to confidentiality are: (a) - If there is evidence of clear and imminent danger of harm to self and/or others, a psychologist is legally required to report this information to the authorities responsible for ensuring safety; (b) - State law requires that psychologists who learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age must report this information to child protection services; (c) - A court order, issued by a judge, may require Quiron Psychology to release information contained in records and/or require a psychologist to testify in a court hearing.*

I have read and understood the above information about confidentiality and its exceptions. I accept it.

Agreement: We appreciate prompt arrival for appointments. Please notify us if you will be late. Twenty-four hour notice of cancellation allows us to plan ahead, and offer the appointment time for others in need. If you cancel or fail to attend an appointment without the 24 hours notice, you may be charged a ‘cancellation fee’ of AUD 80.00. No appointment confirmations will be sent via text; once the appointments are booked, they are automatically confirmed.*

I have read, understood and agreed with the information above.

Intake and Consent Form

Address

Contacts

Address:

Po Box 159
Broadbeach QLD 4218

Contact:

Gustavo Gallo Bolzani