Teen Client Intake Form

Client information

First Name *

Last Name *

Birthdate *

Age *

Gender *

Cell phone *

Can we leave a message? *

YesNo

Email Address *

Can we e-mail you? *

YesNo

Home Address (Street, number, suburb, state and the post code) *

Currently in school *

YesNo

School Name *

What Year are you in? *

If you are currently in a school, are you happy in the school you are in? *

What best describes your teen / tween relationship (Multiple Choice) *

Have a boyfriendDon't have a boyfriendIn my first tween/teen relationshipI think I might be in an un-healthy tween/teen relationshipI am in a happy tween/teen relationshipI was in a tween/teen relationship but broke upIt is complicatedOther

If other

Who is responsible for your account payment? *

Email address of person responsible for account *

Mother or Next of Kin

Name (Next of Kin) *

Surname (Next of Kin) *

Relationship (Next of Kin) *

Cell phone (Next of Kin) *

Father or Next of Kin

Name (Emergency Contact) *

Surname (Emergency Contact) *

Relationship (Emergency Contact) *

Cell phone (Emergency Contact) *

General health and mental health information

Who referred you?

Are you currently seeing a psychologist or counsellor? *

YesNo

Have you previously received any type of mental health services? *

YesNo

Name of therapist

Date or year visited

Reason for previously receiving support?

Have you ever been on medication for your problem? *

YesNoN/A

Please list medication and what it was for

Have you had any side effects on the medication

Have you spoken to your GP about the side effects? *

YesNoN/A

What is the main reason/s you are seeking support and any other information you think might be important? *

How long have you experienced this problem? *

How are you currently managing your problem? *

Is there anything you find difficult talking about feel free to use this space to write down your thoughts.

Family Mental Healthy History

In this section below identify if you or any of your family member identify with any of the following.

Anything else about your family history

Additional Health and Mental Health Information

Please list any specific health problems you currently experience

Please list any specific sleep problems you currently experience

Do you get nightmares or dream a lot? *

YesNoN/A

Can you remember your dreams? *

YesNoN/A

How many times a week do you exercise? *

What types of exercise do you participate in? *

Would you benefit form Walk and Talk counselling Sessions? *

YesNoNot sure, I want to know moreN/A

Please list any difficulties you experience with your appetite or eating patterns

Are you currently experiencing overwhelming sadness, grief or depression? If yes please explain *

Are you currently experiencing overwhelming anxiety, panic attacks or have any phobias? If yes please explain *

Do you currently have any suicidal thoughts? *

YesNo

Explain current thoughts *

Have you ever experienced suicidal thoughts? *

YesNo

Explain previous thoughts *

Are you currently experiencing any chronic pain? *

YesNo

If yes please explain and what is your pain level out of 5 (1 Not bad to 5 Very bad)

Experimentation with alcohol and drugs during adolescence is common if this applies to you please answer these questions

Have you experimented with alcohol or drugs before *

YesNoN/A

Do you drink alcohol? *

YesNoN/A

How much alcohol do you consume per week?

Has alcohol ever had a negative impact on your life or your relationship with friends and family members?

Would you like to drink less or quit your alcohol use? *

YesNoN/A

Do you vape? *

YesNoN/A

Have you ever experimented with vaping? *

YesNoN/A

Can you go withou your vape for a day or two and it does not bother you at all? You don't even think of it during those two day's. *

YesNoN/A

If you are currently vaping how often do you vape?

DailyWeeklyMonthly

What make vape do you use and how often do you use it?

Do you currently use any drugs? *

YesNoN/A

Have you ever experimented with drugs? This includes things like weed, bongs, nangs, chroming *

YesNoN/A

If you are currently using recreational drugs how often do you use?

DailyWeeklyMonthly

What drugs do you use or used in the past

Have you looked for help to stop your drug use before?

FDV Questions

These questions are related to tweens and teens who are in un-healthy relationships. It is also related to young people who are growing up in FDV relationships. If the client prefers not to write anything here but would like to rather talk aobut it in their session that is absulutely fine.

Are you experiencing Family Domestic Violence *

YesNoN/AOther

Explain Current Situation

Are you in a tween or teen un-healthy relationship

YesNo

Other Information about your tween / teen relationship

What other significant life changes or stressful events have you experienced recently?

Additional Information

Do you consider yourself to be spiritual or religious?

YesNoN/A

If yes, what is your faith or belief

What do you consider to be some of your strengths

What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy? (Write down some of your goals)

Informed Consent and Disclosure Statement for Counselling Services

Privacy Policy

Azelene Williams Privacy Policy

1. Introduction

Azelene Williams is committed to protecting your privacy. This Privacy Policy explains how we collect, use, disclose, and safeguard your information when you visit our website azelenewilliams.com, or engage with our services. By using our website and services, you agree to the collection and use of information in accordance with this policy.

2. Information We Collect

We collect various types of information, including:

Personal Information: Name, email address, phone number, and other contact details.

Sensitive Information: Information related to your mental health, treatment history, and other sensitive data relevant to our counselling services as part of our intake process.

Usage Data: Information on how you interact with our website, such as IP address, browser type, and pages visited.

3. How We Use Your Information

We use your information to:

Provide and manage our counselling services.
Communicate with you, including responding to inquiries and providing updates.
Improve our services and website.

Comply with legal obligations and the Australian Association of Social Workers (AASW) and Australian Counselling Association (ACA) guidelines.

4. Disclosure of Your Information

We do not share your personal or sensitive information with third parties except:

With your consent.
To comply with legal requirements or respond to lawful requests by public authorities.
To protect and defend our rights and property.

5. Data Security

We take reasonable steps to protect your information from unauthorized access, use, or disclosure. However, no method of transmission over the Internet or electronic storage is 100% secure.

6. Your Rights

You have the right to access, update, or delete your personal information. You may also object to the processing of your data or request restrictions. To exercise these rights, please contact us at azelenewilliams@gmail.com

7. Changes to This Policy

We may update this Privacy Policy from time to time. We will notify you of any changes by posting the new policy on our website. Your continued use of our services after any changes constitutes your acceptance of the new Privacy Policy.

8. Contact Us

If you have any questions about this Privacy Policy, please contact us at:

Email: azelenewilliams@gmail.com
Phone: +61 405 246 176

Terms of Service

Azelene Williams Terms of Service

1. Introduction

These Terms of Service ("Terms") govern your use of the Azelene Williams website and services. By accessing our website and services, you agree to comply with these Terms.

2. Services

Azelene Williams offers counselling, coaching and public speaking services. These services are provided in accordance with the guidelines set forth by the Australian Association of Social Workers (AASW) and the Australian Counselling Association (ACA).

3. Client Responsibilities

Clients are expected to:

Provide accurate and complete information during the counselling process.
Attend scheduled sessions on time and notify us of cancellations at least 24 hours in advance.
Engage in the counselling process with an open and honest approach.

4. Confidentiality

All client information is kept confidential, except in situations where disclosure is required by law or necessary to prevent harm to the client or others. For more details, please refer to our Privacy Policy.

5. Payment and Fees

Fees for services are outlined on our website or discussed during the initial consultation. Payments are due at the time of service unless otherwise arranged. We accept direct transfers, direct deposits, and PayPal.

6. Cancellation and Refund Policy

Clients must notify us of cancellations at least 24 hours before the scheduled session. Failure to do so may result in a 50% cancellation fee. Refunds are handled on a case-by-case basis.

7. Limitation of Liability

Azelene Williams is not liable for any direct, indirect, incidental, or consequential damages arising from the use of our services. Our liability is limited to the amount paid for the services rendered.

8. Governing Law

These Terms are governed by the laws of Western Australia, without regard to its conflict of laws principles.

9. Changes to These Terms

We may update these Terms from time to time. We will notify you of any changes by posting the new Terms on our website. Your continued use of our services after any changes constitute your acceptance of the new Terms.

10. Contact Us

If you have any questions about these Terms, please get in touch with us at:

Email: azelenewilliams@gmail.com
Phone: +61 405 246 176

Consent and Agreement for Child under 18 years of age.

I give consent that my child undergo Psychotherapeutic Holistic Counselling with Azelene Williams.

I fully understand the process of counselling and art therapy and the outcome I can expect. I fully understand that counselling is a process and not an immediate cure and does not in any way replace any medical treatment my child might need now or in the future.

I fully understand that should my child’s life be in danger in any way I need to inform the Police and Azelene immediately.

I do understand that the Azelene has the right to report any emotional, physical or sexual abuse to authorities if needed.

If Azelene feels at any point that she is not able to meet the outcomes, she will discuss it with you, and then either end the services, or refer your child to the appropriate professional.

I do understand that Azelene has a current, working with children check, and police clearance, and is qualified to work with children.

Childs Name and Surname *

Parent / Next of Kin Name and Surname *

Date *

Signature *

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