Consent Form

Fees

The counselling fee for individuals is $130 for an hour session and $150 for couples. Payment can be made by internet transfer on the day of the counselling session.

Please complete the form below

Name

First Name

Last Name

Title

Date of Birth

YYYY

Age

Marital Status

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact number

Referring Doctor

Patient family information: Please list ages and gender of children.

Patient Relationship Status (ignore if client is a minor).)

Medical conditions

Medications

Person to contact in an emergency

To ensure your privacy, all other personal details will be discussed at time of consultation

Consent Form

CONFIDENTIALITY Please be assured your confidentiality is protected at Life Choice Counselling Solutions therefore you can feel free in the safe and protected environment to discuss the issues that are troubling you. All information gathered by the counsellor during the provision of the counselling service will remain confidential and secure except when: 1. It is Subpoenaed by a Court 2. Failure to disclose the information would place you or another person at risk; or 3. Your prior approval has been obtained to (A) provide a written report to another professional or agency eg. a GP or a lawyer, WorkCover or an Insurance Company or (B) discuss the material with another person eg. a parent or employer.

Declaration

I have read the above details and agree to partake in counselling at Life Counselling Solutions.

I consent

Life Counselling Solutions

Life Counselling Solutions - Changes that create harmony. Based at Maroochydore on the Sunshine Coast specialising in Relationship Counselling, Grief and Loss, Eating disorders, Chronic health problems, Stress and Family conflict/breakdown.

Consent form

Consent Form

Fees

Please complete the form below

Life Counselling Solutions

Phone: 0409 528 016

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