INTAKE REGISTRATION FORM Please complete prior to your first session BelowStart your recovery journey today with a 20 minute initial consultation. Book from anywhere in the world. Access addiction recovery resources and therapy today.1800 841 890 "*" indicates required fields Step 1 of 4 25% Personal InformationFirst Name* Last Name* Street* Unit City* State/Province* Postal Code* Home Phone Mobile Phone Email Address* Date of Birth* DD slash MM slash YYYY Gender*MaleFemailRelationship Status Occupation* Hours per week Referred by Emergency ContactFirst Name* Last Name* Relationship Home phone Mobile phone Email Address Family History Family Illnesses/AddictionsRelation Illness/Addiction Relation 2 Illness/Addiction Relation 3 Illness/Addiction Personal Health History Medical DiagnosisDiagnosis Current Past Date of Onset DD slash MM slash YYYY Diagnosis 2 Current Past Date of Onset DD slash MM slash YYYY Diagnosis 3 Current Past Date of Onset DD slash MM slash YYYY Supplements or Substances List all supplements and medications you’re currently taking including vitamins, herbs, minerals. Also list if you are using any substances, how much and how often including cigarettes, alcohol and other drugs.Supplement Dose Frequency Start Date DD slash MM slash YYYY Reason Supplement 2 Dose Frequency Start Date DD slash MM slash YYYY Reason Supplement 3 Dose Frequency Start Date DD slash MM slash YYYY Reason Do you have any current physical issues, such as pain or other conditions? Have you tried any other therapies? If so please list below. LifestyleHow many hours do you sleep a night? Do you have trouble falling asleep? Staying asleep? You wake frequently during the night? Do you wake feeling rested? Yes No Do you exercise? If yes, what types of exercise do you do? What do you do to have fun? How do you express your creativity? What level of stress are you currently experiencing? List your main stressorsPlease provide any other information that may be relevant but hasn't been covered in regard to emotions EnvironmentWhere do you currently live? City Country What type of environment did you grow up in? What was your parents relationship like, how was school etc? Are there any negative recurring patterns in your life? Ok to leave blank if you are not sure. Describe your goal/s for attending these sessions.How do you want to feel or what do you want to achieve out of the program?What is your level of commitment to improving your life? 1 2 3 4 5 6 7 8 9 10 1 = Lowest, 10 = HighestPatient Consent Clause and Teletherapy Waiver We require your consent to enable us to handle personal information about you and conduct your treatment. If you have any questions or concerns about this, please feel free to ask for a further explanation. I understand that: I am not obligated to provide any information requested of me but that my failure to do so might compromise the quality and outcome of the health care and treatment given to me. My health records are confidential and case notes taken during my consultation are de-identified and stored on a secure server that is not accessible outside of Inner Help Pty Ltd. Under no circumstances will my private information be disseminated or otherwise shared, unless legally requested via subpoena or police warrant. I am aware of my right to access the information collected about me, except in rare circumstances where information may be withheld, and I understand that I will be given an appropriate explanation in these circumstances. I consent to the sharing of my information with other practitioners of Inner Help Pty Ltd in a confidential manner in circumstances where it is deemed necessary to ensure a high standard of care. My private information will not be shared with any persons or practitioners outside of (Your CompanyName) without my prior consent in writing. I understand and accept that the treatment provided by Inner Help Pty Ltd is not Guaranteed to heal/rehabilitate and there are no refunds provided once the program/session has commenced and total fee for the chosen program is payable. I release any liability on-site or on-site while under Inner Help Pty Ltd’s care, direction or advice and release Inner Help Pty Ltd from any liabilities such as overdose, death or injury incurred or claims to damages. I acknowledge that I may be referred to another medical practitioner when my case exceeds the expertise or scope of practice of the practitioners within Inner Help Pty Ltd to ensure duty of care. Teletherapy Waiver: I,Teletherapy Waiver:* hereby consent to engage in teletherapy with Inner Help Pty Ltd.I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that teletherapy/coaching also involves the communication of my medical/mental information, both orally and visually. I understand that I have the following rights with respect to teletherapy: 1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. 2. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. 3. I understand that there are risks and consequences from teletherapy, including,but not limited to, the possibility, despite reasonable efforts on the part of Inner Help Pty Ltd, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorised persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. 4. In addition, I understand that teletherapy based services and care may not be as complete as face- to-face services. I also understand that if Inner Help Pty Ltd believes I would be better served by another form of therapeutic services (e.g. face to-face services) I will be referred to a professional who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not be improved, and in some cases may even get worse. and I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured. 5. I accept that teletherapy does not provide emergency services. During our first session, my allocated therapist and I will discuss an emergency response plan. If I am experiencing an emergency situation, I understand that I can call 000 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support. 6. I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. I understand that while email may be used to communicate with Inner Help Pty Ltd, confidentiality of emails cannot be guaranteed. 8. I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law. I have read, understood and agreed with the information provided above. Cancellation Policy: I agree that any missed or rescheduled sessions without at least 24 hours notice will be forfeited without refund. I agree that my session/program will not be able to be refunded once commenced.Client/Parent As a parent/guardian I consent for my child/dependant to attend a Root-Cause Therapy Session/s. By signing below I am providing confirmation and consent that I have read and accepted the above conditions and the information provided on this form is true and correct: Print Name* Date* DD slash MM slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
