Birthday*

Consent to contact emergency contact in an emergency:

Marital Status:*

Children*

Have you previously attended therapy or counselling?

Is your GP involved in your Mental Health care? If so, please provide details (they will not be contacted without your consent)*

Any other health care provider involved in your Mental Health Care? If so, please provide details (they will not be contacted without your consent)*

Please check any conditions or diagnosis you have or have had in the past:

Please check any symptoms you are currently experiencing:

By submitting this form, you confirm you’ve read, understood and agree to Terra Soul Therapies’ Consent and Confidentiality Policy. You acknowledge your right to discuss or withdraw consent at any time, except where required by law (as per AHPRA & PACFA)*

Do you consent to Terra Soul Therapies contacting your GP or other healthcare providers to support your care, only with your prior permission and for care continuity purposes? Consent will always be sought before any contact is made.*

Payment Policy: Payment is required in advance of each session to confirm your booking.*

Cancellation Policy: Please provide at least 24 hours’ notice to cancel or reschedule. Sessions cancelled within 24 hours require full payment, except in genuine or unforeseen circumstances.*