Intake Form | Shifting Perspective Counselling

Counselling on the Sunshine Coast for Life’s Challenges and Transitions

Confidential, compassionate, client-centered counselling and therapy on the Sunshine Coast

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Thank you for taking the time to complete this intake form before your first session. Your responses help me understand what has brought you here and how I can best support you.

Please answer as openly as you feel comfortable. You don’t need to have everything perfectly explained. This is simply a starting point for our work together.

Contact Details

First name

Last name

Phone

Birthday

Day

Month

Year

Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Contact Information

Name

Phone Number

Relationship to you

What brings you to counselling?

How did you hear about us?

Multi choice

School

Word of mouth

Website

Pamphlet

Google Search

Other

Presenting Concerns

What has brought you to counselling at this time?

How long have you been experiencing this?

What would you like to feel different by attending counselling?

Have you had counselling before? If yes, what was helpful or unhelpful?

Mental Health & Medical History

Mental Health

Previous diagnoses (if any)

Current symptoms

Anxiety

Low mood

Grief/loss

Burnout

OCD

ADHD

Sleep Issues

Medical

Current medications

Physical health conditions

GP name and clinic

Have you had thoughts of harming yourself in the past month?

Yes

Have you ever attempted to harm yourself?

Yes

Are you currently feeling unsafe?

Yes

Any history of self-harm?

Substance use concerns?

Current Support

Do you currently have anyone to rely on for support?

Are you working with any other health professionals?

Relationship status

Living situation

Signature

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Your Privacy Matters

Everything you share in this form and in our sessions is treated with care, respect, and confidentiality. Your information is securely stored and handled in accordance with Australian privacy laws and the Australian Counselling Association (ACA) Code of Ethics.