Intake Form

Please complete this form before your first appointment.

Step 1

Contact & logistics

Step 2

Health snapshot

Step 3

Goals & focus

Need a pause? Take a break and return when you feel ready. Grounding resources live in the Client Care Hub.

The Financial Therapist

Name (required)

First Name

Last Name

Email (required)

Mobile Phone Number (required)

Address (required)

Country

Address Line 1 (required)

Address Line 2

Suburb (required)

State (required)

Postcode (required)

Date (dd/mm/yyyy) (required)

Occupation

Are you currently in any form of relationship?

Do you have any children?

Next of Kin (In case of emergency)

Phone number for Next of Kin

How would you consider your general health?

1 — 5 scale (1 = very poor, 5 = excellent)

Have you previously seen a counsellor or psychologist?

Are you on any medication from any previous issue?

If yes, medication details

Are you currently experiencing overwhelming sadness, grief or depression?

Have you ever had any suicidal thoughts?

Has any family member identified with any mental health issue?

How would you consider your sleeping habits?

1 — 5 scale (1 = very poor, 5 = excellent)

How would you rate your current physical health?

1 — 5 scale (1 = very poor, 5 = excellent)

Do you do any form of exercise? If so, how often?

Are you currently experiencing any form of chronic pain?

Are you currently using any alcohol or drugs for pain management?

Have you recently used any recreational drugs?

What is the main reason/s you are seeking therapy?

Is there any other information you think might be important?

Intake Form

Intake FormEnquiry Form Consent Form

Contact: Dan Lobel

dan@themelbournecounsellor.com.au

0467 477 786

The Financial Therapist Pty. Ltd. atf The Financial Therapist Trust.

The Financial Therapist acknowledges the Wurundjeri people who are the Traditional Custodians of the land on which we work.

If you or someone you know is in crisis and needs help now, call triple zero (000).

Lifeline — Call 13 11 14.

Suicide Call Back Service — Call 1300 659 467.

Beyond Blue — Call 1300 22 4636.

MindSpot — Call 1800 61 44 34.

Medicare Mental Health — Call 1800 595 212.

MensLine Australia — Call 1300 78 99 78.

FriendLine — Call 1800 424 287.

Kids Helpline — Call 1800 55 1800.

Headspace — Call 1800 650 890.

Sane Australia — Call 1800 187 263.

Blue Knot Foundation — Call 1300 657 380.

13Yarn — Call 13 92 76.

Thirrili — Call 1800 805 801.

QLife — Call 1800 184 527.

Panda — Call 1300 726 306.

ForWhen — Call 1300 24 23 22.

Gidget Foundation — Call 1300 851 758.

Open Arms — Call 1800 011 046.

Butterfly National Helpline — Call 1800 33 4673.