Confidential Client Intake Form:

Please complete the questions below. The information you provide will help your Counsellor, Nekitta Blomeyer, to get to know you better. Once this information has been completed, we will then have an introductory meeting on Zoom before we begin our counselling journey. Nekitta will send you a link for you to book this next step.

Counselling Intake Forms
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country
6. Please tick below if you are experiencing any of the following elements:
6. Please tick below if you are experiencing any of the following elements:
I take note of and understand that the person that I am going to consult with is not a psychologist or a psychiatrist, but a Counsellor who is registered with the Council for Counsellors of South Africa (CCSA).
I take note that it is my responsibility to be attentive of all appointment dates and times. If late for a session, the session will consist of the remaining allocated time. If you are unsure of the appointment time, please contact your Counsellor to confirm.
Personal particulars are voluntarily disclosed by the client and will form part off the permanent confidential file, which will remain the property of this practice. However, if the client discloses any information indicating intent to harm his or herself or harm someone else, the counsellor is obligated to act upon this information through discussion with the Autonomic Coaching team.
I understand that my case might be confidentially discussed with the Autonomic Coaching team.
The Protection of Personal Information Act 4 of 2013 (POPIA) is the comprehensive data protection legislation enacted in South Africa. The updated POPI Act came into effect on 1 July 2021. The act requires that we obtain your consent to communicate with you in future.By ticking this option, you are proving consent for us to communicate with you from the personal information you have provided.