Consent Form

Please fill out the following form in order to attend your counselling session.

All fields must be filled out if you are joining us for the first time.

If you have previously consented, please tick Yes, already consented on bottom of this form.

First name

Last name

Phone

Date of Birth

Address

Gender

Female

Male

Other

Partner Status

Children

Emergency Contact

Phone Mobile & Work

Relationship

Clients Occupation

Address

Medical and Wellbeing Profile

General Health History – please list any current medical diagnoses/illnesses/conditions you have. For example – cardiovascular disease, asthma, diabetes, depression/anxiety, Bi-polar, ADHD, autism etc……

Please list recent and current symptoms. For example – headaches, anxiousness, sleeplessness, emotional, reactive, chest pain, breathing difficulty, body aches and pains etc..….

Phone

Address

Specialist

Phone

Address

Practitioner

Phone

Address

Current Treatments

Medications/Supplements….

What is the main reason for your visit….

Consent

By signing this form, I have understood, and agree to receive, the Pet Grief Counselling, which have been explained to me.

By signing this form:

I consent to the initial and ongoing counselling consultations with the counsellor I have booked into see.
I agree that this consent form will remain active for future consultations with this service.

I understand and/or accept - (please tick)

I can ask questions at any time.

I can withdraw consent for treatment at any time.

Full responsibility for receiving treatment.

This consent also includes subsequent treatments at this clinic.

My signature below is a declaration that all information I have provided on this form (including physical conditions and medical diagnosis) is accurate and complete to the best of my knowledge and I have made full disclosure of all my medical conditions including current medications.

By signing your name, you're consenting this is your digital signature.

Date

Signature

I declare that the info I’ve provided is accurate & complete

Yes, already consented previously.