Psychosocial Consultation Intake & Consent

The Psychosocial Intake Form is designed to gather comprehensive information about your psychological, social, and emotional well-being. This information will help us understand your current situation, and tailor our services to you. Please complete all fields, if a field does not apply you may enter ‘N/A’; If you have any questions or need assistance while completing the form, please do not hesitate to contact our office for support.

Please note the following:

  • A signature is required, which you can do easily from any mobile device, tablet or computer.
  • Fields do not save and the form must be completed in one sitting. It will take about 10 mins to complete.
  • If you are in a partnership each person is to complete their own form.
  • Click Submit when done.

 

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Personal Information

Full Name
Partner's Name: This is needed to ensure your files are linked before your session. If you are a single applicant, please write 'N/A"
Address

History and Personal Information

To assist your Therapist in preparing for your consultation. Please complete all fields, put N/A if not applicable.
Please describe your childhood family experience?
Please select one
Indicate name, dose and purpose
Marital Status
What is your current occupation and educational history?
How would you describe your social interaction
Are you involved in any custody, access dispute, disagreement or any legal difficulties
What is your stress level?
How would you rate your physical health?
Do you drink alcohol?
Do you use recreational substances?
Do you have concerns about your substance use?
Current Symptoms: Please select all that are relevant today.

CONSENT 

Psychosocial Interventions 

This form is the written expression of my voluntary and informed consent to engage in professional social work services, in the context of a psychosocial interview.

I understand that I may withdraw from the social work service at any time. Further, I understand that information and records are kept in a secure and confidential manner.

I further understand that following my conversation with Your Counselling Ltd a summary report will be made available to the fertility clinic, or the consultant agency, that I am working with. I understand that the summary report then becomes the property of the fertility clinic and any further disclosure of the aforementioned report will be made in accordance with their disclosure policies.

I understand that Your Counselling Ltd. does not retain formal copies of the report but rather the intake notation and information only. I further understand that the summary report will be transmitted to the clinic via a PDF document and attached to an electronic mail message. Further to this, I release Your Counselling Ltd. with any liability associated with transmission and disclosure.

I understand that should I wish to obtain a copy of the report I will have to request it from the referring agency and or clinic in accordance with their process and procedures.

By placing my electronic signature below, I understand that it is if I am signing in person.  I further understand that consent will be verbally reviewed prior to engagement in any social work intervention and that should I have any questions regarding this consent I have the ability to ask prior to the interview occurring.

Clear Signature
Upon signing, you are indicating that you have read and understood this consent form. You agree to accept the services as detailed above.