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Client Intake Form (Rebalance)

Client Information

We do require you to complete & submit the intake & consent form prior to coming in for your appointment to allow your therapist enough time to review the information.

First Name

Last Name

Preferred Name

Date of Birth

Mobile Number

Address

Gender

Gender
A
B
C

Relationship Status

Nationality

Religion

Occupation

What concerns bring you in? Kindly provide as much detail as you can.

Have you consulted a mental health professional in the past? If yes, please provide further information.

Emergency Contact Information

Name

Relationship

Phone Number

Referral Information

How Did You Find Out About Us?

CONSENT FOR COUNSELLING

At Rebalance, we believe all our clients should be aware of the terms and conditions of our practice. Please feel free to question or ask for more information at any time. 


Confidentiality

We respect your privacy and as such each session is confidential. There are exceptions to this rule however: 

• Any perceived risks towards harming yourself or others 

• Anything that may indicate child abuse 

• Valuable medical information in case of emergency 

 • Court orders for disclosure of information 

It is important to note, in any of the above situations, we provide only information that is needed for each situation; we endeavour to protect our client privacy as much as possible. In the event of any of the above situations occurring, we would strive to contact you to inform you of the need to disclose, and discuss this with you. We take client confidentiality very seriously and will endeavour to keep your data safe by limiting access to only counsellors who are involved in your care, and the supporting of internal processes.

Cancellation Policy

We do ask that you provide a minimum of 24 hours notice if you cannot attend your appointment. Failure to do so will result in being charged the full fee for the appointment.

Personal Data Protection

Your personal information given through online registration forms, email, phone or any other communication channel will be kept strictly confidential. Information collected is shared only with our authorised staff for the purpose of providing better services. By voluntarily providing your personal data in order to obtain our services, it will be deemed that you have consented to the collection, use, disclosure and processing of your personal data by us for the purposes related to the provision of providing professional services to you. We do not disclose personal data to third parties except when required by law, or referrals to other healthcare professionals and/or institutions as agreed with you via consent in writing. This information may include, but is not limited to session notes, invoices for insurance claims, and other items relating to you and the care you receive.  For more information, please review our Privacy Policy which can be found on our website.

By ticking this box, I consent to Rebalance collecting my personal data for registration and communication purposes. I have read and fully understand this consent form.

By ticking this box, I consent to Rebalance collecting my personal data for registration and communication purposes. I have read and fully understand this consent form.

By ticking this box, I consent to periodically receiving information regarding our upcoming workshops and events at Rebalance

By ticking this box, I consent to periodically receiving information regarding our upcoming workshops and events at Rebalance

Client acknowledgment and agreement to the consent form (please sign)

Signature

For payment before session via PayNow (UEN 53399118L):

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