Intake Form

Maddy Goodwolf

Art Therapist I IFS Practitioner I Yoga Teacher

CONFIDENTIAL

Contact Information:

As part of providing a therapeutic service to you, Maddy collects and records personal information that is relevant to your current situation. Information is gathered only as needed, and is a helpful part of the assessment and counselling. Please be assured it is only seen by Maddy and complies with the legal requirements of the National Privacy Principles outlined in the Privacy Amendment (Private Sector) Act 2000. Please feel welcome to talk with Maddy if you have any questions or concerns.

First Name

Date of Birth

Last Name

Name of parent/guardian (if applicable)

Phone

Is it OK to leave reminders, messages on this number?

Is it OK to send information to this email address?

Contact in case of Emergency

Relationship to you

How did you hear about Maddy? (eg friend, GP, website, other)

Would you like to go on Maddy’s email list to receive information about art therapy, IFS therapy and creativity workshops?

CONFIDENTIALITY

Conversations and information shared in counselling sessions are respected and kept confidential. The only instance where Maddy may need to talk to someone outside the service is if she has concerns about your safety or someone else’s. Wherever possible, Maddy will talk with you first before doing so. If you are unsure what this means, please feel welcome to talk further with Maddy before you sign this form.

FEES

The fee for service is $120 for a 60-minute individual therapy session. If you wish for a longer session the cost is $150 for a 90 min session. Payment is due on the day of each session via direct transfer. Please pay:

Madeleine Goodwolf

BSB: 633 000

ACC: 154 942 510

SESSION ATTENDENCE

If you need to reschedule a session please give more than 24 hours notice so someone on our waiting list can be offered an appointment. Cancellations or changes received with less than 24 hours notice or non-attendance without notice will be

charged the full session fee.

I understand the information provided about Confidentiality and agree to the terms about Session Attendance as outlined above.

Your Signature

Date

Thank you, Maddy.