A safe, supportive space for emotional wellbeing and personal growth.
Please fill in this form before your first session. All information is kept strictly confidential.
Please note: The Psych Wellbeing is a counselling and therapy practice. We are a non-medical service. We do not provide any medical diagnoses, prescribe medications, or offer psychiatric treatment. If you require medical or psychiatric services, please consult a qualified medical doctor or psychiatrist. Our counsellors and therapists are here to support your emotional wellbeing, personal growth, and mental wellness through talk-based therapy only.
Fields marked * are required.
Once completed, download the form as a PDF or send it directly to your therapist.
1 Personal Information
2 What Brings You Here
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3 Your Emotional & Personal Background
Note: We do not prescribe or manage any medications. This helps us understand your full picture of care.
4 Your Day-to-Day Wellbeing
5 Safety & Additional Information
This is a safe space. Your answer helps us ensure you receive the right level of support.
6 Consent & Agreement
Counselling & Therapy Service: I understand that The Psych Wellbeing provides counselling and talk-based therapy only. This is a non-medical, non-psychiatric service. No diagnoses will be made and no medications will be prescribed.
Confidentiality: I understand that everything I share with my counsellor is kept strictly confidential. The only exceptions are situations where there is a serious safety risk to myself or others, as required by professional ethics.
My information: I consent to the collection and use of the information I have provided in this form for the purpose of counselling and therapy at The Psych Wellbeing. This information will not be shared with anyone outside the practice without my permission.
Voluntary participation: I understand that I am free to end counselling at any time and that I can choose not to answer any question I am not comfortable with.
I confirm that the information I have provided is accurate and complete to the best of my knowledge.