Mary Mackenzie Counselling and Coaching Bcouns(Coaching)
ABN: 42 924 742 481
New Client Details:
Name: ________________________________________________________
Address: ______________________________________________________
______________________________________________________________
Email: ________________________________________________________
Mobile #: _____________________________________________________

Consent:
As a part of the counselling service offered, I may collect and record notes that are relevant to your current situation. The purpose of these notes is to keep an accurate description of your sessions for reference purposes only. These notes will be retained by myself only and remain completely confidential. As a client you have access to these notes if requested. 
Confidentiality:
All information exchanged and recorded during your counselling sessions will remain confidential and secure except under the following conditions:
1) There is a court Subpoena
2) Failure to disclose would place yourself or another person at serious and imminent risk. This includes physical or sexual abuse to persons under the age of 18. 
Or, your approval has been given for requested disclosure to another professional such as a lawyer or employer.
I,  ...............................................................................   have read and understood the above consent form. I agree to these conditions provided by Mary Mackenzie Counselling and Coaching.

Client Signature...........................................................................................                         Date...............................

Mary Mackenzie Signature ………………………………………………………………                         Date........................