Counselling Intake and Contract Client Name Referral date Referral type Date initial appt. Date ended Total no. sessions DNAs Cancelled Total cancel/DNA Subjects discussed for YES/NO if Discussed contracting Record keeping Confidentiality Child protection Alcohol/intoxicants Cancellation at short notice Payment method Insurance Missed appointments Team and other professionals Address Telephone Health issues Social circumstances Medication Name of parent/guardian if under 16 years of age Address Telephone Presenting issues, including goals and expectations Previous experience of counselling/therapy First review to initial contract, including goals and expectations Counsellor's signature Client Signature Word Count: 146 Date Date Client address and Contact Details GP contact details Address Permission to contact GP Y N Contact required Dates of contact Telephone Other psychiatric/psychological services Y N Name of professional Permission to contact other psych service Y N Contact required Professional's discipline ..... Dates of contact Address