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To book either for face-to-face or online therapy please complete the form below. When you complete the form you will be able to book. Please note: information provided on this form is protected as confidential information under the practice confidentiality statement. Booking for: Online therapy Face-to-face therapy (Conditions and suitability apply re online therapy. See terms at completion and signature stage of this form)

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Date

Personal Information

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State Postcode

Date of birth

Age

Gender

Parent/Legal Guardian (if under 18):

Phone

(Please note: Email correspondence is not considered a confidential medium of communication).

Name of next of kin:

First Last

Phone

Next of kin:

I am booking for:

Individual therapy (private – no Mental Health Care Plan)

Individual therapy (on a Mental Health Care Plan – MHCP)

Couples/Relationship Therapy

Individual therapy (on a Mental Health Care Plan – MHCP)

Mental Health Care Plan:

Doctor’s Name:

Doctor’s Practice

Doctor’s Address:

Street Address City State Postcode

Medicare Number:

Reference (next to name):

Expiry:

Individual therapy (private – no Mental Health Care Plan)

History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?(Required)

Yes

Previous therapist/practitioner/practice:

Are you currently taking any prescription medication?(Required)

Yes

please list:

Have you ever been prescribed any psychiatric medication?(Required)

Yes

please list and provide approximate dates:

General and Mental Health Information

1. How would you rate your current physical health?

Please list any specific health problems you are currently experiencing:

2. How would you rate your current sleeping habits?

Please list any specific sleep problems you are currently experiencing:

3. How many times per week do you generally exercise?

Not at all

Once

Twice

Three Times

More than three times

What types of exercise do you participate in?

4. Please list any difficulties you experience with your appetite or eating problems:

5. Are you currently experiencing overwhelming sadness, grief or depression?

Yes

for approximately how long?

6. Are you currently experiencing anxiety, panics attacks or have any phobias?

Yes

7. when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Yes

please describe:

8. Do you drink alcohol more than once a week?

Yes

9. How often do you engage in recreational drug use?

10. Partnership Status:

Never Married

Domestic Partnership

Married/De Facto

Separated

Divorced

Widowed

How long?

11. On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your current relationship?

12. What significant life changes or stressful events have you experienced recently?

Family Mental Health History In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, brother, sister, uncle, etc.) Please Check the box and List Family Member

Alcohol/Substance Abuse

Yes

Family Member Name

Anxiety

Yes

Family Member Name

Depression

Yes

Family Member Name

Domestic Violence

Yes

Family Member Name

Eating Disorders

Yes

Family Member Name

Obsessive Compulsive Behaviour

Yes

Family Member Name

Schizophrenia

Yes

Family Member Name

Suicide Attempts/Suicide

Yes

Family Member Name

Additional Information

1. Are you currently employed?

Yes

pleases note this practice cannot afford to bulk bill

what is your current employment situation?

Casual

Part-time

Permanent Part-time

Full-time employed

Contractor

Do you enjoy your work?

Yes

Mostly

Sometimes

Is there anything stressful about your current work?

2. Do you consider yourself to be spiritual or religious?

Yes

describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

5. What would you like to accomplish out of your time in therapy?

History

Couples/Relationship Therapy

Personal Information

Partner 1 Name:(Required)

Partner 1 Date of birth:(Required)

Partner 1 Age:(Required)

Partner 1 Gender(Required)

Partner 1 Address:(Required)

Street Address City State Postcode

Partner 1 Phone:(Required)

Partner 1 Email:(Required)

Please note: Email correspondence is not considered a confidential medium of communication

Partner 2 Name:(Required)

Partner 2 Date of birth:(Required)

Partner 2 Age:(Required)

Partner 2 Gender(Required)

Partner 2 Address:(Required)

Street Address City State Postcode

Partner 2 Phone:(Required)

Partner 2 Email:(Required)

Please note: Email correspondence is not considered a confidential medium of communication

The details of Couples Therapy are outlined on the practice website (Main Menu under 'Couples').

A booking for Couples Therapy may only proceed after both partners have completed the Gottman Relationship Questionnaire.

Booking must be made for the initial four intake sessions.

Permission to video or audio record therapy sessions:

As a primary tool in Gottman Method Couples Therapy and Emotionally Focused Couples Therapy, and in order to augment your therapy work, I may use videotape or audio tape feedback as part of therapy sessions. This means that I may ask to videotape you during specific dialogues or exercises, or during entire sessions. We may play back these tapes in sessions to help you see patterns of behaviour between partners and to help you process conflicts. By viewing the videotapes in sessions, it allows us to "stop action" and process how you might approach a conflict in a more productive way. It also allows you to witness your progress as your relationship becomes more satisfying to both of you.

In addition to in-session use, I may wish to use the videotapes to receive consultation from Drs. John or Julie Gottman or an independently practicing couples therapist who has received training from The Gottman Institute, or my professional Emotionally Focused Therapy peer supervisor. This may occur during the time of treatment or thereafter for purposes of peer review, education and quality assurance. During this process, your name will be kept confidential. In addition, all matters discussed in consultations will remain completely confidential within the Gottman Institute staff or with my professional peer supervisor. The video tapes are not part of your clinical record and will be used for no other purpose and they will be erased when they are no longer needed for these purposes.

These tapes are my property and will remain solely in my possession during the course of your therapy. Copies may be sent under secure electronic conditions to the Gottman Institute or my professional Emotionally Focused Therapy peer supervisor, for the purposes noted above. These materials will remain in locked facilities at all times.

Family Therapy (not court related)

Family Therapy offered is Emotionally Focused Family Therapy (EFFT).

Personal Information

Partner 1 Name:(Required)

Partner 1 Date of birth:(Required)

Partner 1 Age:(Required)

Partner 1 Phone:(Required)

Partner 1 Gender(Required)

Partner 1 Address:(Required)

Street Address City State Postcode

Partner 1 Phone:(Required)

Partner 1 Email:(Required)

Please note: Email correspondence is not considered a confidential medium of communication

Name of next of kin (other than partner):(Required)

Name of next of kin (other than partner) Phone:(Required)

Partner 2 Name:

Partner 2 Date of birth:(Required)

Partner 2 Age:(Required)

Partner 2 Phone:(Required)

Partner 2 Gender(Required)

Partner 2 Address:(Required)

Street Address City State Postcode

Partner 2 Phone:(Required)

Partner 2 Email:(Required)

Please note: Email correspondence is not considered a confidential medium of communication

Name of next of kin (other than partner):(Required)

Name of next of kin (other than partner) Phone:(Required)

Child 1 Name:

Child 1 Date of birth:

Child 1 Age:

Child 1 Gender

Child 2 Name:

Child 2 Date of birth:

Child 2 Age:

Child 2 Gender

Child 3 Name:

Child 3 Date of birth:

Child 3 Age:

Child 3 Gender

Child 4 Name:

Child 4 Date of birth:

Child 4 Age:

Child 4 Gender

Legal Matter

For all legal matters contact the practice to discuss requirements to allow Chapman Marques Psychology and Relationship Counselling to decide whether the matter can be accepted and details for your next step(s).

Legal Matters relate to Family Dispute Resolution; Family Therapy; Child Wishes Reports to assist the Family Law Court.

Family Dispute Resolution is undertaken by Chapman Marques Mediation P/L – see: (WEBSITE LINK)

In e-signing and booking, I agree to the Confidentiality and Cancellation Policies below:

CONFIDENTIALITY AGREEMENT

Your full name

Address

Street Address City State Postcode

agree that confidentiality will not apply in the following situations:

I disclose any abuse of a child, elder, or person with disability, or, if, on the part of my treating psychologist, they have reasonable grounds to suspect such abused has occurred, or is current;

I disclose I have committed, or intend to commit, a victim-crime;

If there is any statement or behaviour indicating I am contemplating, or have attempted, self-harm;

If a subpoena requires my treating psychologist to provide my files to a court;

If I am referred by a medical practitioner under a Mental Health Plan or Enhanced Primary Care Plan, my psychologist is required to communicate with the referring doctor(s);

(In addition, I agree that my treating psychologist may communicate with my medical practitioner(s) or persons listed hereunder:

GP:

Address

Street Address City State Postcode

Other:

Address

Street Address City State Postcode

Other:

Address

Street Address City State Postcode

CONFIDENTIALITY AGREEMENT

I agree that confidentiality will not apply in the following situations:

I disclose any abuse of a child, elder, or person with disability, or, if, on the part of my treating psychologist, they have reasonable grounds to suspect such abused has occurred, or is occurring;

I disclose I have committed, or intend to commit, a victim crime;

If there is any statement or behaviour indicating I am contemplating, or have attempted self-harm;

If a subpoena requires my treating psychologist to provide my files to a court;

If I have been referred under a Mental Health Care Plan, my psychologist will be able to communicate with the referring doctor.

I am aware that my treating psychologist may communicate with my medical practitioner(s) and persons listed hereunder:

Address

Other

Address

Other

Address

I agree that I have read and understand this Confidentiality Agreement and Cancellation Policy of Chapman Marques Psychology and Relationship Counselling and agree to the terms. I agree that I have had the opportunity to ask any questions.

ONLINE TERMS & CONDITIONS

Telehealth Terms & Conditions

Online therapy may occur via telephone or computer.

Disclosure and consent form for telehealth sessions

As part of providing a psychological service to you, Chapman Marques Psychology & Relationship Counselling needs to collect and record personal information from you that is relevant to your situation, such as your name; contact information; medical history; and other relevant information as part of providing psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted. This information is provided by your completion of the Intake Form. You also complete the Confidentiality Agreement. Following is the required form for Telehealth.

Provision of a telehealth service

Where appropriate the telehealth service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. Chapman Marques Psychology & Relationship Counselling will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services.

To access telehealth sessions, you will need access to a quiet, private space; and the appropriate device, i.e. smartphone; laptop; iPad; computer with a camera; microphone and speakers; and, a reliable broadband internet connection.

If you use a smartphone or mobile device, ensure you remain stationary as the reception may be impacted by your movement. You are reminded driving whilst using a smartphone is illegal.

The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses Zoom which is compliant with the Australian standards for online security and encryption.

Limitations of telehealth

A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session. In addition, there may be some conditions or services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.

Fees

The cost of a consultation as per our fee schedule available on our website or may be given to you by Reception, which is payable by card prior to the session. (The practice does not accept cash or cheque). If you have a Mental Health Care Plan you pay post session. Your GP can advise on your eligibility for Medicare or other compensable funding. It remains your responsibility to check your entitlements from any private health fund. The practice cannot provide this information.

Telehealth Cancellation Policy

The Cancellation Policy is included with our fee statement in your Intake Form. Note carefully the policy conditions.

I, agree, that with respect to online telehealth sessions, the following applies:

I consent to telehealth services and the terms and conditions of the practice

I agree that my suitability for online telehealth is at the discretion of the therapist at all times.

I agree not to record sessions in contravention of the Privacy Act.

I agree not to share any materials made available online.

I have provided the physical location of my telehealth session and will notify any changes.

I have access to a secure and reliable internet platform and am able and willing to use the platform.

My internet access is reliable.

I will have a mobile phone available to use in the case of internet difficulties occurring.

I do not have a disability (e.g. hearing), or spoken language difficulty with English, or other factors that may pose a barrier to accessing telehealth services. (Difficulties with spoken English may require you employ a qualified interpreter. The practice cannot rely on anyone known to you).

I do not display significant risks to myself or others.

I have not had suicidal thoughts.

I will ensure complete privacy during my telehealth sessions.

There is no significant risk if I am overheard by others during their therapy session, i.e., where there is any form of abuse or family violence occurring.

The environment in which I will be located in for telehealth will not be too loud or distracting, to myself or the therapist.

Children or pets will not be present or interrupt the session.

I have social supports (reliable family, friends, contact details for appropriate professionals).

I have had the opportunity to ask questions if required.

General Terms & Conditions

Consent and Agreement Form for Psychological Service & Cancellation/Non-attendance policy

Please read and sign. By booking for sessions with Chapman Marques Psychology & Relationship Counselling you agree to these terms and conditions.

If you are booking for Relationship Counselling both partners need to sign individual copies of this form.

Booking for Online Therapy requires completion of the additional terms and conditions for online/telehealth service.

Psychological Service

As part of providing a psychological service to you, Chapman Marques Psychology & Relationship Counselling needs to collect and record personal information from you that is relevant to your situation, such as your name; contact information; medical history; and other relevant information as part of providing psychological services to you. This collection of personal information will be a necessary part of the intake for psychological assessment and treatment that is conducted.

Confidentiality and Disclosure of personal information

Personal information gathered as part of service by Chapman Marques Psychology and Relationship Counselling will remain confidential except when:

1. it is subpoenaed by a court; or,

2. failure to disclose the information would place you or another person at serious risk to life, health or safety in the opinion of your psychologist; or

3. your prior approval has been obtained either to a) provide a written report to another professional or agency. e.g., a medical specialist; lawyer. b) discuss the material with another person, e. g. a GP; lawyer; a parent; employer; or health provider; other specified person; or c) disclose the information in another way, e. g. email, fax

4. you would reasonably expect your personal information to be disclosed to another professional or agency (e. g. your GP or medical specialist) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or

5. disclosure is otherwise required or authorised by law. This is interpreted as you confess to or state you are contemplating a victim crime e. g. you disclose child, elder, or disability abuse or the psychologist is required by law to lodge a mandatory report.

6. If I have been referred by my doctor, I note Chapman Marques Psychology & Relationship Counselling will communicate with my doctor as required by Medicare

GP(Required)

Practice(Required)

Phone(Required)

In circumstances where the psychologist is concerned about my welfare and is unable to contact me permission is provided for the psychologist to contact the person(s) listed below

Nominated Contact person 1:

Phone (person1)

Nominated Contact person 2:

Phone (person2)

Cancellation Policy

The Australian Psychological Society recommended cancellation fee general guideline is as follows:

“Fees for cancellation of appointments made for psychological services can be justified if no replacement service is billed for the lost time”.

Chapman Marques Psychology and Relationship Counselling adopts this industry standard policy and practice.

Chapman Marques Psychology and Relationship Counselling cancellation policy is as follows:

Less than 5 business days’ notice = 25% the cost of your appointment
Less than 2 business days’ notice = 50% the cost of your appointment
Less than 1 business days’ notice = 100% cost of your appointment
(NOTE: Business days are all days except Saturdays, Sundays and ACT Public Holidays).

“No show, no notice” = 100% of the cost of your appointment.

These fees apply if the appointment slot has been unable to be filled.

You will be charged a cancellation fee, regardless of the reason for the change or cancellation (e.g. you will still be charged if it is due to work or health reasons). If you provide a medical certificate the cancellation fee will be waived.

The fee for simply not attending an appointment will be referred to the Small Claims Court if left unpaid. No further appointments can be made if there is an outstanding fee.

Notification of cancellation must be provided by either: phoning the practice and speaking to a receptionist or leaving a voice message containing your name, phone number, the date and time of the appointment, and the reason for the cancellation; or, emailing those details to reception1.cmprc@gmail.com. Please provide as much notice as possible of any cancellations or changes. Please do not make an appointment unless you are confident that you will be able to attend it.

Consent

In booking, I agree that I have read and understand and accept the General Terms and Conditions and the Confidentiality Agreement and Cancellation Policy of Chapman Marques Psychology and Relationship Counselling (if relevant) and Online Therapy Consent. I agree that I have had the opportunity to ask any questions.

Partner 1 Name:(Required)

Partner 1 Signature(Required)

Partner 2 Name:(Required)

Partner 2 Signature(Required)

Signature(Required)

Date(Required)

Thank You.