YOUR RELATIONSHIP AND GOALS What has brought you to couples counselling at this time? *
What would each of you hope to gain from counselling?
Have you attended relationship counselling previously? Choose 1 Yes No
If yes, what was helpful or unhelpful?
Are there any cultural, language, accessibility or other needs you would like us to consider?
YOUR SAFETY AND WELLBEING Your emotional and physical safety are important. Sometimes relationship conflict, intimidation, control or violence can make joint counselling unsuitable. Where appropriate, I may offer separate check-ins to understand each partner’s needs and discuss safe options.
Would you like to speak privately about a safety or wellbeing concern? Choose 1 Yes No
You do not need to describe a private safety concern on this shared form.
ABOUT COUPLES COUNSELLING What to expect from couples counselling
Counselling offers a supportive setting to understand relationship patterns, improve communication, manage conflict and strengthen connection. The process may include assessment, active therapeutic work, maintaining progress and planning for future challenges. I aim to work fairly with both partners without taking sides. Counselling does not provide legal or financial advice, and outcomes cannot be guaranteed.
Benefits, challenges and your choice
Therapy can support greater understanding and positive change. Exploring difficult topics may also bring sadness, frustration or temporary tension. Progress can take time, and both partners are encouraged to speak openly about comfort, goals and any concerns throughout the process.
Confidentiality and privacy
I handle information shared in counselling with care and in accordance with applicable Australian privacy requirements and professional ethical standards, including those relevant to ACA and PACFA. Records are stored securely, and access is limited to authorised purposes.
Because couples counselling involves 2 people, we will discuss how private information and individual conversations are managed. My approach encourages openness while also respecting safety and privacy. If something raised individually may affect our joint work, we can discuss appropriate next steps respectfully and with sensitivity.
Confidentiality has legal and safety limits. Disclosure may be required or permitted where there is a serious risk of harm, child protection obligations or a lawful order. Where safe and appropriate, I will explain this before sharing information.
You may request access to or correction of personal information in line with applicable law. Joint records may include information about both partners, so requests will be considered in a way that respects each person’s privacy.
Assessments and professional consultation
If questionnaires or other assessments may help, their purpose and use will be explained. I may discuss clinical themes in professional supervision, with appropriate confidentiality safeguards and identifying details minimised wherever possible.
Communication between sessions
For general matters relating to your shared counselling, including both partners in communications is encouraged. If you have a personal safety concern, you may contact me separately. Email and mobile contact are not monitored continuously and are not suitable for urgent assistance.
Emergency and crisis support
Mind Therapy Room does not provide an emergency or crisis response service. In immediate danger, call 000. For 24-hour emotional support in Australia, call Lifeline on 13 11 14.
Optional session recording
Sessions are not recorded unless the purpose is explained in advance and both partners provide separate, informed consent. You may decline without affecting your counselling.
Questions or concerns
If anything in this form is unclear, please raise it before or during counselling. Your questions are welcome, and it is important that both partners feel informed and comfortable about the process.
INFORMED CONSENT FOR COUPLES COUNSELLING Please read the following statements. By typing your names below, each partner confirms that they understand the counselling process and have had an opportunity to ask questions.
I understand the purpose and collaborative nature of couples counselling. I understand that difficult emotions may arise and that outcomes cannot be guaranteed. I understand the confidentiality arrangements and their safety and legal limits. I understand that participation is voluntary and I may pause or withdraw my consent. I agree to participate respectfully and raise any questions or concerns as needed. We’ve read the privacy policy, and we consent to Mind Therapy Room collecting and securely storing this information to provide our counselling. We understand this form is read during business hours, and for urgent support we’ll call 000 or Lifeline on 13 11 14.
Thank you for completing this form. I look forward to supporting both of you through a thoughtful and respectful process.
Fields marked * are required. Your form goes to Louis only.
