Consent & Intake Form

Please complete in full before your first session

Full name

I have read and understood the Statement of Understanding

I understand that my referrer will be informed of any non-attendance or late cancellations (under 24 hours)

I understand that reports will be submitted to my referrer after initial, interim (if applicable) and final session (if requested in referral)

Address (include postcode)

Please tick if you consider yourself to live in a rural/remote location

Mobile number

Date of birth

Month

Day

Year

Ethnicity

Gender

Pronouns

GP Practice name

GP Name

GP Address and postcode

GP Contact Number

Next of kin name

Phone number

Relationship

Health and medications comments

Client Consent & Intake Form 2026