Counselling - Client Details Form

First Name

Last Name

Date of Birth

Gender

Please specify

Address

Address 1

Suburb

Postcode

State

Use this address as my postal address

Postal Address

Address 1

Suburb

Postcode

State

Mobile Phone No.

For minors, please use phone number of primary caregiver

Home Phone No.

Work Phone No.

Email

Emergency Contacts

Enter in order of priority. Minimum 2 emergency contacts.

GP Details

First Name

Last Name

Phone Number

Address

Medications

Please specify any medications currently taking

Reason for Presenting / Referral (Other)

Other Important Information

Family Relationship to Patient (if applicable)

Patient's Name

Patient refers to the child with cancer or deceased child

Client Relationship to Patient

Client refers to individual receiving counselling

Patient's Diagnosis

Patient's Social Worker