• Client Intake Form / Terms & Conditions

    (Online & F2F)
  • Today's Date*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Martial Status:*
  • Current Employment:*
  • Would you prefer for your Counsellor to contact you by:*
  • Have you ever been to Counselling or seen a Psychologist before?*
  • Would you benefit from the services of a Personal Trainer / Nutritionist?
  • Do you regularly use alcohol?*
  • Do you smoke tobacco?*
  • Do you currently have any issues around substance abuse?*
  • Medical History (please tick all that apply)*
  • Have you ever attempted to kill or harm yourse*
  • Have you ever been treated for any of the following? (Tick all that apply)*
  • General Health Questionnaire

    This questionaire is for me to gather a greater understanding around your current medical and if there are any complaints. Please note that I want to know the answer to the present and how you have been most recently and not to the past.
  • Have you recently been able to concentrate on your normal routine and day to day tasks?*
  • Have you been keeping yourself busy and occupied?*
  • Recently, has your sleep been impacted due to worry or stress?*
  • Are you spending much time outdoors and out of the house?*
  • Would you say that you are doing things well recently?*
  • Have you been satisfied with the way you have been carrying out your routine, tasks and work?*
  • Have you maintained a good connection with those around or near you?*
  • Have you felt capable of making decisions about things?Better than usual*
  • Would you say that you have been loosing confidence within yourself?*
  • Have you still been able to enjoy normal day to day activities?*
  • General Service Agreement

  • YOUR THERAPIST

    As a professional Counsellor and Therapist, I follow guidelines and ethics set out by my professional body British Association for Behavioural and Cognitive Psychotherapies (BABCP) who I have a current membership with and is the lead organisation for CBT in the UK and Ireland.

    Outside of my work, I ensure to stay updated with additional training, my own supervision and seek my own professional therapy when required. At The Flawed Journey, I ensure to have the correct approach towards each individuals needs which will make you feel at ease, comfortable with the process and give you step by step care to ensure your not on your Counselling journey alone at any point.

    The Counselling approach I have is mainly person centered, meaning I work along with you providing support and encouragement to attain the most positive outcome for your situation. I work with other therapy models including CBT (Cognitive Behavioural Therapy) and my therapeutic approach is relaxed and informal with a focus on the ‘now’ and how we together can help you move forward more positively. She believes building a strong rapport with clients is key to effective counselling. The process is of healing and recovery but it also takes time and dedication so what you put in is what your therapist will support you with and I assure you the process will be a lot smoother if we work together having a collaborative approach. 

    PRIVACY & COLLECTION POLICY

    The Flawed Journey / ABN: 27824878485 complies with The General Data Protection Regulation 2016/679 and the applicable Privacy Principles in the GDPR when handling personal information, together with The General Data Protection which is a regulation in EU law on data protection and privacy in the European Union and the European Economic Area. It also addresses the transfer of personal data outside the EU and EEA areas when handling personal information which is health information. The Flawed Journey takes the protection of your personal information seriously. Personal information includes any information or opinion, whether true or not, about a person who is identified or whose identity can reasonably be established.

    The Flawed Journey collects personal information for the purposes of providing you with a counselling service. As part of this service, it is possible that the practice may need to collect information about things like how to contact you to arrange an appointment. The Flawed Journey may collect information via the practice Consent Forms or other company forms that you complete, via our online Acuity booking system if you use that and via administration, or through our website www.theflawedjourney.com.

    It is important that you are aware that failure to provide The Flawed Journey with all the information requested, means that The Flawed Journey may not be able to deliver the counselling services that you have requested.

    QUALITY & SECURITY OF DATA COLLECTED

    The Flawed Journey takes reasonable steps to protect personal information collected and secure it from misuse, loss and interference and from unauthorised access and modification. The Flawed Journey endeavours to ensure all such information collected is up-to-date and complete at the time it is collected, used or disclosed.

    To ensure your information is accurate, please notify The Flawed Journey. You can do this by emailing theflawedjourney@gmail.com.

    FOUNDATION

    The Client believes that The Flawed Journey has the necessary qualifications, experience, insurance and abilities to provide services to the Client and the Contractor is agreeable to providing such services to the Client on the terms and conditions set out in this Agreement.

    IN CONSIDERATION OF the matters described above and of the mutual benefits and obligations set forth in this Agreement, the receipt and sufficiency of which consideration is hereby acknowledged, the Client and The Flawed Journey (individually the "Party" and collectively the "Parties" to this Agreement) agree as follows:

  • SERVICES PROVIDED

    1. The Client hereby agrees to engage the The Flawed Journey to provide the Client with the following services:

    ALL CLIENTS:

    o I understand that it is my responsibilty to read this policy and only sign if I fully agree.
    o I understand that I have 48 hours to cancel / reschedule my appointment and that I will be invoiced 24 hours prior to my agreed session date & time with The Flawed Journey. Payment is accepted via bank transfer / paypal - fee is to be paid 1 hour before our agreed session and no later than 24 hours after the session, receipts can be issued upon request.
    o I understand that my therapist is a mental health professional and therefore has a professional relationship at all times with the client, your therapist is not your friend and shouldn't be communicated with outside of sessions in an unprofessional manner as this will not be tolerated.
    o I understand that my therapist will not accept abusive or inappropiate language from any client and the therapist has the right at any point if feeling uncomfortable to stop sessions and if there is a situation where a client has been inappropriate they will be banned from having further sessions with The Flawed Journey.
    o I understand that my Counsellor is not a medical doctor and therefore cannot prescribe medication of any kind, however throughout therapy I may be referred to my doctor if necessary.
    o I’m aware that Counselling provides confidential support, therefore everything discussed within my sessions will be private and kept between myself and my therapist.
    o I understand that my therapist will not release any of my information disclosed within a Counselling session, without my prior permission and this will only be in circumstances of the client's or others safety being at risk.
    o I understand that my Counsellor has a duty of care to report something that threatens my wellbeing or the wellbeing of others around me, this also depends on the laws within your country and will always be communicated first.
    o I understand that all Counsellors have different approaches and I may have to try more than one therapy session before I can identify if the sessions are best suiting my needs.
    o I understand that my Counsellor may work through different approaches and some may make me feel uncomfortable but I have the right to object at any point and right to communicate how I feel directly to my therapist or by emailing - theflawedjourney@gmail.com.
    o I understand that my therapist will maintain my safety and confidentiality of sessions at all times during Walk N Talk therapy but my therapist is not liable for any sickness, injuries or accidents whilst participating in our sessions.
    o I understand that my individual therapy sessions will last 50-60 minutes, Couples / Group Therapy will normally run 60-90 minutes.
    o I understand that if I’m late to my appointment, I will still have to end my session at the allotted time.
    o I understand that my Counsellor can only provide a rough estimate on how many sessions I may need, this is due to every person and situation being different. Some problems can be successfully resolved in a few sessions, in other cases we may have to go deeper into unresolved issues that need further exploration.
    o I understand that if my Counsellor becomes unwell or something unexpectiliy happens and therefore has to take time off, that I will be referred to another Counsellor in a similar area until my Counsellor is fit to return to work as normal.
    o I understand that if I have a booked Walk N Talk session, it depends on the weather and I do have the option to reschedule the session to another time or switch to Phone or Zoom if possible and must be agreed between therapist.
    o I understand that my Therapist is required to take steps to protect my personal information in line with the Commonwealth Privacy Act (1988) including misuse, interference / loss, unauthorized access, modification and disclosure.

    LIMITS TO CONFIDENTIALITY:

    All personal information gathered by The Flawed Journey during the provision of services remains confidential except when:

    1) It is subpoenaed by a court; or Failure to disclose the information would, in the reasonable belief of The Flawed Journey place you or another person at serious risk to life, health or safety; or

    2) Your prior approval has been obtained to:

    a) provide a written report to another professional or agency;

    b) discuss the material with another person;

    c) disclose the information in another way; or

    3) You would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or  

    4) Disclosure is otherwise required or authorised by law.

    FEES & CHARGES:

    o I understand that I will be charged a late cancellation fee (100% of flat rate) if I fail to give at least 48 hours’ notice to cancel or reschedule my scheduled appointment.
    o I understand I will be charged a (100% of flat rate) no – show fee of if I fail to show for my appointment without giving 48 hours notice to the therapist.
    o I understand that I will be invoiced 24 hours prior to my agreed session date & time with The Flawed Journey. Payment is accepted via bank transfer / paypal - fee is to be paid 1 hour before our agreed session and no later than 24 hours after the session, receipts can be issued upon request.
    o I understand that I will be charged for my session as per my currency rate of location, fees are affordable and suitable to my circumstances and will always be agreed in the consultation prior to the first session.
    o I understand once I agree to the flat rate at the beginning of the sessions that there will be no amendments or changes of these fees including if the company's fees increase at anytime.
    o I understand that these charges are out of pocket expense and that I won’t be eligible for a rebate (includes medicare and insurance).
    o Except as otherwise provided in this Agreement, all monetary amounts referred to in this Agreement are in GBP.
    o The Flawed Journey will charge the Client an agreed fee which will be between the Therapist & Client in the consultation prior to the first session. Sessions outside of regular business hours can be arranged for an additional fee where needed but must be agreed and paid in full prior to the session date. Walk N Talk sessions are available mobile so there will be an added % to the fee to cover the therapist's travel time to the session location.
    o Any client who fails to pay an outstanding invoice or has more than 2 no-shows will be banned from having further services with The Flawed Journey.

    ONLINE TELEHEALTH CLIENTS:

    o In order to successfully participate in Online or Telehealth sessions both the client & therapist will need – Good lighting (webcam use), a private confidential space, no interruptions for duration of session, computer / smart device, reliable internet connection, headphones.
    o For each therapy session, you will receive an email invitation for your e-Counselling Zoom session. Click on this link at your allotted therapy time, and you will automatically be connected to your therapist, or put in to a virtual waiting room until your therapist becomes available. This link will change for each of your sessions.
    o Details of the appointment will not be shared publicly or sent to any of your mobile devices. You will receive your Zoom meeting details via email from theflawedjourney@gmail.com to your email address we have on file.
    o Each Zoom video meeting you have with your therapist we will provide you with a different meeting ID & password.
    o The client and therapist must wear noise cancelling headphones for the duration of the session this way no one around the area can listen in to the session.
    o I understand that it is my own responsibilty to ensure I am safe for the duration of the session and checking that windows / doors are closed to ensure no one around is listening into the session.
    o I consent to communicate using phone / videoconference.
    o I understand that it is my own responsibility for costs incurred in data usage.
    o I understand the limitations to confidentiality as a result of communicating electronically and have a responsibility in protecting my own privacy.
    o I consent for my Therapist to call on the contact number provided if there is any interruptions with the zoom video  session.
    o I understand that I have no authority or right to record the session and nor does my Therapist at any time.
    o I must ensure I am in a private comfortable space for the duration of the session, whilst having a drink of water and some tissues nearby.

    CRISIS SERVICES

     

    I understand that my Counsellor is not available 24 hours and is not a crisis service so if you are in need of urgent support or help please don't contact me but do reach out to one of the below services which are available 24 hours / 7 days per week to provide crisis support.

    NI HELPLINES:

    o ALCOHOLICS ANONYMOUS – 0845 769 7555
    o VICTIM SUPPORT – 0808 168 9111

    o SAMARTIANS – 116 123 (freephone) / email jo@samaritans.org (24/7) & jo@samaritans.ie (24/7).
    o PIETA HOUSE – 1800 247 247 / email

    For further 24/7 helplines in another country, search Befrienders and find listed 24/7 helplines in your location - https://www.befrienders.org/

    INSURANCE COVER

    The Flawed Journey's therapists are both fully qualified mental health Counsellors / Psychotherapists, registered and hold insurance where needed to provide their services.

    SERVICE AGREEMENT

    2. The Services will also include any other tasks which the Parties may agree on. The Flawed Journey hereby agrees to provide such Services to the Client.
    3. The term of this Agreement (the "Term") will begin on the date of this Agreement and will remain in full force and effect until the completion of the Services, subject to earlier termination as provided in this Agreement. The Term of this Agreement may be extended with the written consent of the Parties.
    4. In the event that either Party wishes to terminate this Agreement prior to the completion of the Services, that Party will be required to provide 5 days' written notice to the other Party.
    5. The Parties agree to do everything necessary to ensure that the terms of this Agreement take effect.

    MODIFICATION OF AGREEMENT
    6. Any amendment or modification of this Agreement or additional obligation assumed by either Party in connection with this Agreement will only be binding if evidenced in writing signed by all parties involved.
    7. The Flawed Journey will not voluntarily, or by operation of law, assign or otherwise transfer its obligations under this Agreement without the prior written consent of the Client.
    8. This Agreement will be governed by and construed in accordance with the laws of the country, state, and/or province where the service is performed.

    ACCESS, UPDATES & COMPLAINTS

    The Flawed Journey will provide you with access to your personal and health information that has been collected, subject to any legal exceptions, at your written request. Please also let us know if you have any concerns, questions or complaints so that The Flawed Journey can address them promptly for you, by sending an email to theflawedjourney@gmail.com. Where are our records are found to be inaccurate, The Flawed Journey will promptly correct any inaccuracies on the grounds of updated information that you provide.

  • Is it your statement that you have answered and completed all forms in a truthful and honourable manner?*
  • I have read and understood this Consent Form, and agree to the above conditions for the telehealth service provided by The Flawed Journey.

  • Clear
  • Thank you for choosing The Flawed Journey to support you in your journey. If you have any questions, please do not hesitate to contact your therapist via email - alysha.theflawedjourney@gmail.com

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