Counselling Consent Form | The Journey Within

Consent Form

Informed Consent and Release of Liability, Practitioner: Ana Maria Jeremiah of The Journey Within

Client Age

Client Name

Child's Name

Date of Initial Session

Contact No.

Address

Year of Birth

Relationship Status

Educational Level

Occupation

Emergency Contact Name

Relationship

Emergency Contact No

Are you under the care of a physician for any ongoing condition or illness?*

Yes No

If answer is YES

Current & Past Health Issues

Are you in any physical pain, either intermittent or constant?*

Yes No

Are you under the care of a mental health professional? *

Yes No

If answer is YES

Have you ever contemplated or attempted suicide?*

Yes No

If answer is YES

Signed Date

Signature

Terms

By clicking here & typing my name, I state that I have read and understood the Terms and Conditions