1 | YOUR DETAILS Welcome. Please complete what feels comfortable to share. This information helps me understand your circumstances, needs and hopes for counselling. You can discuss any answer privately during your appointment.
Full legal name *
Email address *
Residential address
Preferred contact SMS Phone Email
Is it safe to contact you? Choose 1 Yes No
If no, please describe a safe contact method or time
6 | HEALTH AND MENTAL HEALTH HISTORY Have you received a mental health diagnosis? Choose 1 Yes No Unsure
If yes, what diagnosis or diagnoses?
Have you been admitted to hospital for mental health support? Choose 1 Yes No Unsure
If yes, please provide approximate date and reason (if comfortable)
Physical health conditions, chronic illness, injuries or pain concerns
Current medications (including dose if known)
7 | SAFETY AND WELLBEING These questions help identify whether extra care or a safety plan may be helpful. You may discuss answers privately.
Currently experiencing thoughts of suicide or self-harm? Choose 1 Yes No
Have you previously attempted suicide? Choose 1 Yes No
Are you concerned about your safety or someone else’s behaviour? Choose 1 Yes No
Would you like to talk privately about any safety concern today? Choose 1 Yes No
You do not need to record sensitive safety details here. We can discuss these safely during your session.
9 | PREVIOUS COUNSELLING AND SUPPORT Have you accessed counselling or mental health support before? Choose 1 Yes No Unsure
Types of support Counsellor GP Psychologist Psychiatrist Support group Other
When, for how long, and what was the main focus?
What was helpful or unhelpful in previous support?
10 | PERSONAL VALUES, STRENGTHS AND SUPPORT Are there cultural, spiritual, identity, language or personal values you would like me to know?
What personal strengths or qualities have helped you through difficult times?
What helps you feel safe, calm or supported?
Who or what is part of your support network?
What activities, interests or goals give you meaning or enjoyment?
Is there anything else you would like me to understand about you?
11 | COUNSELLING INFORMATION AND CONSENT Counselling is a collaborative and respectful process that can support wellbeing, understanding and positive change. Together we can explore concerns and identify approaches suited to your needs. Progress varies, and no particular outcome can be guaranteed.
Your choice and wellbeing
You may ask questions, decline an activity, pause or end counselling at any time. Exploring difficult experiences can sometimes bring temporary emotional discomfort. Please let me know if you feel overwhelmed, concerned or uncertain about any aspect of counselling.
Privacy and confidentiality
Your information and counselling records are handled confidentially, securely and in accordance with applicable Australian privacy requirements and professional ethical standards. Confidentiality has limits, including circumstances involving serious safety concerns, child protection requirements or lawful disclosure obligations. Where practicable and safe, any necessary disclosure will be discussed with you.
Professional consultation and communication
De-identified themes may be discussed in professional supervision. Contact by mobile or email is for general enquiries and appointments and is not monitored continuously. Sessions are not recorded without separate prior consent.
Urgent support
Mind Therapy Room does not provide a crisis service. If you are in immediate danger, phone 000. For 24-hour emotional support in Australia, contact Lifeline on 13 11 14.
12 | ACKNOWLEDGEMENT I understand the general purpose and nature of counselling. I understand the privacy arrangements and their legal and safety limits. I have had an opportunity to ask questions. I understand that counselling is voluntary and that I may withdraw consent. I agree to participate in individual counselling with Louis Chalouhi. I’ve read the privacy policy, and I consent to Mind Therapy Room collecting and securely storing this information to provide my counselling. I understand this form is read during business hours, and for urgent support I’ll call 000 or Lifeline on 13 11 14.
Client full name, typed as your signature *
Thank you for sharing this information. I look forward to supporting you with care and respect.
Fields marked * are required. Your form goes to Louis only.
