PK Kamell

IMPORTANT: The completion and return of this form confirms that you understand and agree with the Terms and Conditions of Consulting with Pollin Kamell, as listed at the end of this form. A copy will be kept on file.

*** PERSONAL DETAILS

Your name

Date of birth

Contact (Email / Mobile / Home / Work)

*** WHAT BROUGHT YOU TO SEEK THERAPY

What is you greatest struggle / main issue?

How do you experience it? How do you think or hope I can help?

How do you relate to the world these days? What is the overall feeling you experience in any given day? How or what do you feel normally?

*** PAST AND CURRENT THERAPY HISTORY

Have you had or are you still having any form of therapy / counselling / support / alternative treatment? Please list the Therapy type, Frequency and Issues addressed

*** MEDICAL AND HEALTH CARE HISTORY

Please outline any specific health or mental conditions that you may have been diagnosed with. Have you been admitted into hospital, institution or care previously? (If so, please outline briefly)

*** MEDICATION DETAILS

Please list all natural or pharmaceutical (prescribed or over-the-counter) medications ... inclusive of any drugs, prescribed or recreational and/or supplements. Please include name, dosage and frequency.

*** RELIGIOUS OR SPIRITUAL BACKGROUND

What is the religious or spiritual background of your family? Has this changed at any point and if so, how?

What are your personal beliefs about life?

*** ADDITIONAL INFORMATION

Is there any additional information you think I should be aware of?

*** TERMS AND CONDITIONS OF CONSULTATION

I hereby confirm that (please tick each point as you read them)

the information provided in the ‘Personal Details and History’ form is accurate and true; and that nothing has been withheld that might compromise the consultant, or my progress in this course of therapy.
I understand that the focus is to empower me for change towards achieving a more fulfilling way of being by helping me to recognise and harness my innate abilities and potential; through the letting go of unnecessary patterns. I understand that this course of therapy is not offered as a healing or cure. It is a process to help me regain my responsibilities and empower me for my evolving life choices and decisions.
I am aware that I am responsible for my personal wellbeing and that I will make contact for clarification or support if any questions, concerns or issues arise before, during and after the sessions. It is my responsibility to ensure that I understand this document fully before agreeing to proceed with a session.
I understand that I am to continue any prescribed medications as advised by my family doctor (GP) and that I will not change any prescribed medications unless I do so with the consultation of my GP.
I will consult with the consultant first and foremost, about my sessions or any matters arising from it.
I will attend all scheduled appointments and if unable to do so, I will contact to cancel or reschedule. I understand that cancellations made with less than 48 hours notice will incur a part charge of the full session, while failure to attend a scheduled appointment will be charged in full. I agree to this.
I understand that the consultant reserves the right to not provide service for me or to end a session based on the consultant’s professional view that 1. there are specific needs that may not be able to be provided for. 2. the client may not be ready or suited to the proposed form of intervention. 3. there may be aspects that could affect the safe and effective delivery of service.
The consultant aims to provide a safe and professional service in the interest of my wellbeing, with my participation. In order to do so, the consultant may from time to time have to discuss aspects of my case with her supervisor or team while maintaining her responsibilities of confidentiality and privacy.
I give permission for the consultant to share generic and non-identifying elements of my issue for the greater learning and development of practitioners with the intention of education and professional development. My privacy is respected.
The consultant will explain and outline the process of the sessions and possible developments that I may experience. Only with my agreement will we proceed into a full session, upon which, I will commit to participate fully in this course of intervention and to complete the exercises set for me by the consultant at the end of each session.
By completing and returning this form to Pollin Kamell, I agree to have my details recorded in her database and to receive correspondence from Pollin Kamell. I can opt to stop this at anytime by sending us a message via the Contact Form or calling 021 566880.
I have read and understand this Terms and Conditions.