Book a Session — Aligned Living

PERSONAL DETAILS

How did you discover this service?

Brochure

Facebook/ Social Media

Psychology Today

Word of Mouth

Website

Other

Name

First Name

Last Name

Date of Birth

Gender

Ethnic Background

Faith Background/Affiliation/Interests:

Spiritual Group/Church attended:

Household composition/Current circumstances:

Spouse/Partner’s Name:

Spouse/Partner’s Occupation

Spouse/Partner's Age

CONTACT DETAILS

Postal Adress

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone Number

Medical Details

Medicare Number & Position Number

Allergies

Medical Conditions

Physical Injuries

Mental Health Conditions

Other

Current Medication

Message

EMERGENCY CONTACT

Name

First Name

Last Name

Relationship to Client

Phone Number

Address

PERSONAL GOALS

Outline what you are hoping to achieve in your time spent with Aligned Living:

PREVIOUS HELP SOUGHT

Have you seen a counsellor, psychologist or psychiatrist before?

If yes, please list their name/s and the year/s seen:

BILLING DETAILS (if different to Personal/Contact details)

Name

First Name

Last Name

Company

Address

Phone

Preferred method of payment

* Surcharge applies1.8% plus 75c

Cash

EFT

Credit Card *

Do you have a current Health Care Card (Centrelink) or Pension Card?

Yes

Type and number if Yes: _____________________Exp: ____ / _____

HORSEMANSHIP EXPERIENCE

Please outline roughly the amount and type of experience you’ve had so far with horses

HORSE RIDING

Please note: If one of your goals is to ride the horse please consider that you must be under 95kg to ensure the horse is comfortable and to avoid injury.

If Riding - Weight (kg), Height (cm) & Head Circumference (cm)

PHOTO PERMISSON

I give permission for any photos/videos taken to be used for advertising and promotional purposes by Aligned Living:

PRAYER PERMISSION

As well as psychological treatments, I would like to ask for prayer for my physical or mental health, past hurts or present circumstances:

LEGAL INVOLVMENT

Do you need us to provide information for a lawyer, court, employer or insurance agency?

SERVICE REQUEST

I would like to engage the following service/s:

Equine Assisted Counselling

Equine Assisted Learning

Body Awareness

Counselling

Retreat

Horse Hangout

Horsemanship Lessons

Horsemanship Clinic

Facilitator Training

Service request for:

Agreement

I agree to the following terms and conditions:- 1. Aligned Living will provide a professional service to support you / your child in reaching your social, emotional, or personal development goals. 2. I will ensure Aligned Living receives payment for any services provided to me / my child within 7 days. 3. I will tell an Aligned Living staff member if I am feeling unsafe for any reason. 4. All information you provide to Aligned Living is confidential and will not be transferred to any third parties except in the case of the following: a. Emergency – if an emergency arises it may be necessary to give your / your child’s information to other health professionals or emergency services. b. Supervision – the Aligned Living practitioner may require assistance from a supervisor in regards to some cases. Some details of the session/s will need to be relayed to the supervisor to facilitate this support. c. Permission – Aligned Living may seek your permission to discuss case details with other health care practitioners who are supporting you / your child. d. Legal – if your therapist is required to provide evidence for a court or other legal hearing. e. Crime – if you mention that you witnessed or committed a serious crime or if the information may prevent a crime being committed. Also if you have evidence or suspicion of abuse towards a minor/disabled/aged person. f. Special Agreement – if you agree separately in writing to allow Aligned Living to use specified information in advertising and promotions 5. Brief notes are recorded after each session, if subpoenaed by a court of law, Aligned Living will be required to submit these notes to the court. 6.If engaging in body awareness, I acknowledge that my facilitator is not formally trained in physical therapy and I will be responsible for my own physical safety. 7. If I cancel my appointment I will give at least 48 hrs notice, if not then I will still be charged for the appointment. Aligned Living reserves the right to be lenient in strenuous situations.

Registration

08 6234 1721 • Coogee Road, Mariginiup WA 6078