Client information

Sex(required)

Can we leave a message?(required)

Can we email you?(required)

Are you currently employed?(required)

What best describes your relationship (Multiple Choice)(required)

Any Children?(required)

Next of Kin

In case of emergency

General health and mental health information

other

Are you currently seeing a psychologist or counsellor?(required)

Have you previously received any type of mental health services?(required)

Have you ever been on medication for your problem?(required)

Have you spoken to your GP about the side effects?(required)

Severity of this problem (1 Not Bad to 5 Very Bad)(required)

Family Mental Healthy History

In this section below identify if you or any of your family member identify with any of the following. 

Alcohol or Substance Abuse

Anxiety Disorder

Clinical Depression

Domestic Violence

Eating Disorders

Obesity

OCD

Schizophrenia

Suicide Attempts

Bipolar Disorder

Dementia

ADHD

Autism

PTSD

Self-Harm

Narcissistic personality Disorder

Additional Health and Mental Health Information

How would you rate your current physical health?(required)

How would you rate your current sleeping habits?(required)

Do you get nightmares or dream a lot?(required)

Can you remember your dreams?(required)

Would you benefit from Walk and Talk counselling Sessions?(required)

Do you currently have any suicidal thoughts?(required)

Have you ever experienced suicidal thoughts?(required)

Are you currently experiencing any chronic pain?(required)

Do you drink alcohol?(required)

Would you like to drink less or quit your alcohol use?(required)

Have you ever used recreational drugs?(required)

If you are currently using recreational drugs how often do you use?

FDV Questions

Are you experiencing Family Domestic Violence(required)

What are you currently experiencing

Have you previously experienced Family Domestic Violence(required)

What have you previously experienced

Rate your relationship out of 5 (1 Not bad to 5 Very bad)

Additional Information

Do you consider yourself to be spiritual or religious?(required)

Informed Consent and Disclosure Statement for Counselling Services

HGB Counselling (Private Practice)

Michael buns (Counsellor)

Diploma of Counselling

Email: [email protected]

Web: hgbcounselling.com.au

COUNSELOR-CLIENT SERVICE AGREEMENT
Welcome to my practice. This document contains important disclosure information about my professional services and business policies. It was created in accordance with the Australian Counselling Association Code of Ethics and Practice of the Australian Counselling Association.
Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
COUNSELING AND PSYCHOTHERAPY SERVICES
Counselling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. The Australian Counselling Association defines “Counsellor and Counselling” as:
Counsellorrefers to anyone delivering what a reasonable person would assume to be a counselling service (see below).
Counselling Servicemeans any service provided by a counsellor to a client including but not limited to:
Counselling activities
Professional activities
Professional practice
Research practice
Supervision
Teaching
As a client in counselling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Counselling has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of counselling often requires discussing the unpleasant aspects of your life. However, counselling has been shown to have benefits for individuals who undertake it. Counselling often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. However, there are no guarantees about what will happen. Counselling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.
Please note, I am not qualified to prescribe medications. If you have a need for a referral, I would be able to refer you.
MY PROFESSIONAL BACKGROUND
Educational Background
Diploma of Counselling: Australian Institute of Professional Counsellors
Diploma of Business Administration: TAFE SA
Professional Development and Training
NDIS Workers Orientation Module– NDIS Quality and Safeguards Commission
Accredited Mental Health First Aider: Mental Health First Aid Australia
Working with Children Clearance: Department of Human Services
Safe Environments for Children and Young People: TAFE SA
MY THERAPEUTIC ORIENTATION
I strongly believe in individualizing treatment, and thus my approach to working with clients may differ according to the needs and preferences of individual and unique clients. I also select different approaches based on age, developmental level, and modality (individual, couple, family). When working with children and adolescents, I tend to conceptualize treatment from a Family Systems perspective, and thus often include parents and other siblings in counselling sessions if needed. If working individually with elementary age children (5 to 10 years old), I tend to use Child-Cantered Play Therapy based on Gary Landreth’s model. If working individually with pre-teens and adolescents (11-18 years old), I tend to use a mixture of more directive and structured approaches such as Cognitive-Behaviour Therapy, Dialectical Behaviour Therapy, and Solution-Focused Therapy, alongside relational approaches such as Interpersonal Therapy. In couples work, I often use Gottman Method Couples Therapy. When working with individual adults, I tend to prefer a Psychodynamic and Attachment-based approach to help individuals connect current relationship and behavioural patterns to their past history.
There are some commonalities in how I approach treatment with every client I work with. For example, I take a strengths-based approach and attempt to highlight the client’s abilities even when working on problems. I also value basic listening and the importance of the client being heard, understood, and validated.
I also offer Walk and Talk Therapy for my clients who would like to be out and about.
PROPOSED COURSE OF TREATMENT
Because each client is a different and unique person bringing individualized problems to work through, the proposed course of treatment may differ for each person. With that in mind, I propose the following for the initial course of treatment. The first 1 – 4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that I often require parents to attend the first four sessions when I am working with a child or adolescent client, before we make collaborative decisions about whether individual or family therapy is indicated.
APPOINTMENTS
I do offer a complimentary 15 session on the telephone of via zoom if required. There after the initial intake session lasts for 60 minutes, and subsequent sessions last for 45 to 60 minutes. Appointments will occur once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without cancelling, or cancel with less than 24 hour notice, my policy is to collect the amount of your co-payment that you will be responsible for (unless we both agree that you were unable to attend due to circumstances beyond your control). If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
INSURANCE COMPANIES
I am not registered with Medicare or any other Private Health insurance companies. Therefor all accounts will be your responsibility and cannot be claimed from any insurance company.
PROFESSIONAL RECORDS
I am required to keep appropriate records of the counselling services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request (i.e., release of information form).
CONFIDENTIALITY
My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. In brief, I will attempt to keep all information you disclose to me confidential, with some notable exceptions outlined below:
You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. In such cases, I must act to protect you from harming yourself. For client and adolescent clients, I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be, and also act to protect you from harming yourself.
You tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In such cases, I must inform the person who you intend to harm. For child and adolescent clients, I must inform both your parent or guardian, and the person who you intend to harm.
You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In such cases, I will need to use my professional judgment to decide whether I need to act to protect yourself or another person from harm. For child and adolescent clients, I will need to use my professional judgment to decide whether a parent or guardian should be informed, in addition to deciding whether I need to act to protect yourself or another person from harm.
You tell me you are being abused physically, sexually or emotionally – or that you have been abused in the past. In this situation, I will need to use my professional judgment to decide whether I need to act to protect yourself or another person from harm. For child and adolescent clients, I will need to use my professional judgment to decide whether a parent or guardian should be informed, in addition to deciding whether I need to act to protect yourself or another person from harm.
You tell me of any child suffering any form of abuse or neglect including child sexual abuse I would need to do a mandatory report.
You are involved in a court case and a request is made for information about your counselling or therapy. If this happens, I will not disclose information without your written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.
You waive your privilege to confidentiality if you bring charges against me.
You have been provided with a copy of the Notice of Privacy Practices and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.
PARENTS/GUARDIANS & MINORS
While privacy in therapy is crucial to successful progress, the involvement of parents/guardians can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents/guardians allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. It is also my policy to require that a parent/guardian be present with the child or adolescent under 18 years of age for the first four sessions so that I can make an accurate assessment about whether individual or family counselling is most indicated. All other communication will require the child’s agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised. [See Adolescent Consent Form, to be signed by both adolescent and parent(s).]
For child and adolescent clients, I will not tell your parent or guardian specific things you share with me in our private therapy sessions except for situations such as those mentioned above. This includes activities and behaviour that your parent/guardian would not approve of — or would be upset by — but that do not put you at risk of serious and immediate harm. However, if your risk- taking behaviour becomes more serious, then I will need to use my professional judgment to decide whether you are in serious and immediate danger of being harmed. If I feel that you are in such danger, I will communicate this information to your parent or guardian. The following are some examples of when disclosing information to parents or guardians might be indicated:
Example 1: If you tell me that you have tried alcohol at a few parties, I will keep this information confidential. If you tell me that you are drinking and driving or that you are a passenger in a car with a driver who is drunk, I will not keep this information confidential from your parent/guardian. If you tell me, or if I believe based on things you’ve told me, that you are addicted to alcohol, I will not keep this information confidential.
Example 2: If you tell me that you are having protected sex with a boyfriend or girlfriend, I will keep this information confidential. If you tell me that, on several occasions, you have engaged in unprotected sex with people you do not know or in unsafe situations, I will not keep this information confidential.
Example 3: In South Australia, people under 16 years old cannot legally consent to having sex, even if they said ‘yes’ at the time. The age of consent is 18 years old if there is a special relationship between them,where one person is in a position of power or authority over the other person. An example of this is the relationship between a teacher and a student, or a sports coach and a team member. I will not keep this information confidential if this law was not abided.
You can always ask me questions about the types of information I would disclose.
Example: You could ask in the form of “hypothetical situations,” in other words: “If someone told you that they were doing ________, would you tell their parents?”
Even if I have agreed to keep information confidential – to not tell your parent or guardian – I may believe that it is important for them to know what is going on in your life. In these situations, I will encourage you to tell your parent/guardian and will help you find the best way to tell them. Also, when meeting with your parents/guardians, I may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to you.
When working with child or adolescent clients individually, I will not share any information with your school unless I have your permission and permission from your parent or guardian. Sometimes I may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for me to give suggestions to your teacher or counsellor at school. If I want to contact your school, or if someone at your school wants to contact me, I will discuss it with you and ask for your written permission. A very unlikely situation might come up in which I do not have your permission but both I and your parent or guardian believe that it is very important for me to be able to share certain information with someone at your school. In this situation, I will use my professional judgment to decide whether to share any information.
When working with child or adolescent clients individually, sometimes your doctor and I may need to work together; for example, if you need to take medication in addition to seeing a counsellor or therapist. I will get your written permission and permission from your parent/guardian in advance to share information with your doctor. The only time I will share information with your doctor even if I don’t have your permission is if you are doing something that puts you at risk for serious and immediate physical/medical harm.
Parent/Guardian:
Reading the following and sign below indicating your agreement to respect your adolescent’s privacy:
I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.
Although I know I have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my adolescent’s treatment.
I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultation with her consultant/supervisor.
CONTACTING ME
I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters.
For emergencies, dial 000 or go to your Local Hospital Emergency Room.
OTHER RIGHTS
If you are unhappy with what is happening in counselling, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, colour, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients. You have the right to choose treatment, to choose your counsellor and treatment modality that best suits your needs, and to confidentiality (with some notable exceptions listed above).
CONSENT TO COUNSELING AND PSYCHOTHERAPY SERVICES
Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.


Consent and Agreement for Adults.


Our practice will work closely with other agencies to coordinate the best support for you. This means your informed consent for the sharing of information will be sought and respected in all situations unless:
* we are obliged by law to disclose your information regardless of consent or otherwise;
* it is unreasonable or impracticable to gain consent or consent has been refused; and
* the disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people.