Client Intake Form

Thank you for choosing to work with me. I look forward to collaborating with you to help you achieve your counselling goals.

Client details

Full name

Date of birth

Phone number

Emergency contact details

Full name

Phone number

Relationship

Name of your GP

Medical Centre

Name of your Psychiatrist and Practice Name (if applicable)

My professional practice does not support clients currently involved in legal proceedings. Do you have any pending or anticipated legal matters that may require court, police, or legal representation within the next 18 months?

Counselling Goals

Please write up to three goals. These goals are what a successful outcome looks like to you. You will know therapy is working when you progress closer towards these goals.

I have read and agree to all terms outlined below this form

I agree

Counselling Agreement & Policies – Please Read Fully

Your first appointment

Your initial consultation is 55 minutes, with subsequent sessions lasting 50 minutes. Payment is required prior to your first session
Please bring photo identification (driver's license or passport) to your first appointment to complete your registration process.

Appointment policy

Please provide 48 hours notice for cancellation or changes via email.
Less than 24 hours notice: 50% fee applies.
Same-day cancellations or no-shows: Full fee applies.

I reserve your appointment time specifically for you and cannot typically fill last-minute vacancies.

Communication

Email is my preferred method of contact, and I aim to respond within 24 hours on business days. You can reach me at ben@chatwithben.co.nz.

Confidentiality

I uphold the New Zealand Association of Counsellors Code of Ethics. Counselling is confidential. However, if there is imminent risk of harm to either you or someone else, I will take reasonable steps to ensure everyone’s safety. This may require consultation with the appropriate third parties.

My Referral ‘Pay it Forward’ Policy

Pay it forward and refer someone to me, and they will get $50 off their first appointment.

This helps my practice grow and allows me to focus on what I do best – serving and helping my clients – instead of focusing on advertising.