Welcome to The Bear Haven Intake Form PARTNER “A” Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Are you of Aboriginal or Torres Strait Islander origin? Aboriginal Torres Strait Islander Neither Relationship Status Single Divorced Separated Married Partner Widowed Remarried Its Complicated Relationship, name & ages of people residing with you: Occupation Emergency Contact One * First Name Last Name Relationship * Phone * (###) ### #### Emergency Contact Two * First Name Last Name Relationship * Phone * (###) ### #### General Practitioner * First Name Last Name Practice Details * Phone (###) ### #### Financial Position Employed Health Care Card Student Pension Unemployed Do you have any mental health diagnoses? (ie. Depression, BPD, Schizophrenia) Yes No If yes, diagnosis Behaviours Present Eating issues Insomnia Withdrawal Poor Concentration Self Harm Vomiting Procrastination Impulsive reactions Can't keep a job Taking risks Sleep disturbance Work to hard Taking Drugs Lack of motivation Crying Avoidance Compulsive behaviour Drinking too much Aggressive behaviour Loss of Control Other Other Feelings Present Angry Hopeless Relaxed Frustrated Guilty Tense Fearful Regretful Sad Anxious Annoyed Unhappy Jealous Miserable Helpless Conflicted Lonely Bored Panicky Worthless Other Other Physical Headaches Tremors Twitches Dry Mouth Numbness Sexual disturbance Skin problems Stomach pain Fatigue Palpitations Unable to relax Fainting spells Chest pain Tingling Excessive sweating Other Other Are you currently using medication? Yes No If yes, what medication are you taking and for what? What do you hope for/expect from counselling? Is there any other information you would like your counsellor to know? How did you here about us? Family Friend Social Media Referral Other Other Confidentiality is maintained for clients as far as possible but when a person or personas are at risk, confidentiality must be waived and the appropriate authorities or emergency contacts notified. Such situations include: 1. The client is at risk of serious self harm or of considering suicide. 2. Of harming another person or committing homicide. 3. Abuse of children is a mandatory reporting offence and by law will be reported. 4. By court order notes are subpoenaed. Where confidentiality cannot be maintained, the counsellor will take all possible steps to first inform/discuss their intention with the client. I have read the above and understand the counsellor's social and ethical responsibility to make such decisions where necessary. I understand and agree to these conditions concerning confidentiality. Cancellation Policy - We appreciate that at times you may find it necessary to cancel your appointment. We require a full 24hours notice of your intention to cancel. Failure to do so will result in you being charged 50% of the consultation Fee. A MISSED CONSULTATION WITH NO NOTICE WILL BE CHARGED AT THE FULL FEE. Do you agree? Yes Agreement Date * MM DD YYYY