THE OFFICE OF THE REGISTRAR Eligibility, appropriateness and referrals: I understand that my eligibility for service is

contingent upon my status as FNU student or employee. The counsellor and I will decide
COUNSELLING SERVICES
whether counselling services are appropriate for my presenting eeds and conditions. I
Informed Consent and Intake Form understand that if it is not, then I will be given referrals to resources more appropriate to
my needs and goals. I have had the opportunity to discuss any questions I have about this
information:
Client’s Name: __________________________ ID#:___________________
Client’s Signature: _____________________ Date: ________________
I understand that the Fiji National University(FNU) is offering counselling services and that
this service is provided by the approved FNU Counsellors. I have discussed this information with the client:

Counsellor’s Name: _______________________________________________

Confidentiality: I understand that all information disclosed during counselling sessions is
confidential and may not be revealed to anyone without my written permission. The only
Signature: _____________________ Date: ________________
exception is in situations where disclosure is required by law:

Intake Form
1. if I present an imminent threat of harm to myself or others;
2. when there is an indication of abuse of a child, dependent adult, or elderly adult;
3. if I become gravely disabled All information provided is held in strict confidence. Tick in appropriate boxes.
4. by court subpoena; and
5. when debriefing with or referring to other FNU counsellors. Full Name: _____________________________________ Date of Birth: ________________

Sex: M / F Religion: ______________________ Marital Status:________________

Communication: I understand that e-mail is not the appropriate way to communicate
confidential, urgent, or emergency information. FNU cannot ensure that e-mail messages Occupation: Staff: Job Title: _________________________ Division: ___________________
will be received or responded to if my counsellor is not available. Therefore, I am Student: Programme: _______________________________ Year: ______________________
encouraged to contact the FNU Counsellors during open hours or utilise the emergency
contacts and call the nearest Fiji Police if I have an urgent need after work hours. Name of sponsor: _________________________________ Hostel: _____________________

Current Address:______________________________________________________________
Digital recording: I understand that my interview/s may be digitally recorded for note-
taking, academic and research purpose without revealing the identity of the client. The Mobile: ___________________ Email: ___________________________________________
recordings are treated confidentially and are deleted after they are used.
Father’s name:__________________________ Occupation: ___________________
Risk and benefits: I understand that there is a possibility of risks and benefits which may
Mother’s name: ________________________ Occupation:____________________
occur in counselling. Counselling may involve the risk of remembering unpleasant events
and may arouse strong emotional feelings. Counselling can impact relationships with Your Parents are: Married Partnered Divorced Separated Widowed
significant others. The benefits from counselling may be an improved ability to relate with
others; a clearer understanding of self, values, goals; increased academic productivity; and Number of brothers: ________________ Number of sisters: _________________
an ability to deal with everyday stress. Taking personal responsibility for working with these Emergency Contact: Name: ________________________ Relation: ____________________
issues may lead to greater growth.
Mobile: ___________________ Address: __________________________________________
What is your current concern(s)? __________________________________________ Describe your childhood?
_____________________________________________________________________ _____________________________________________________________________
_____________________________________________________________________ _____________________________________________________________________
_____________________________________________________________________ Describe your overall school experience?
_____________________________________________________________________
Are you currently receiving help for your current concern? Yes No _____________________________________________________________________
If yes from GP Counsellor Mental Health Team
Are you happy with your current living conditions? Yes No
How has this concern impacted you studies/ work or day to day routine?
If no, specify___________________________________________________________
_____________________________________________________________________
_____________________________________________________________________ If you are in a relationship, how would you describe it?
What strategies have you used to help you cope? _____________________________________________________________________
_____________________________________________________________________ _____________________________________________________________________
_____________________________________________________________________
What do you feel is the cause of your current difficulty? Are you happy with the level of support you receive from family and friends?
_________________________________________________________________________
Yes No If no, specify___________________________________________
_________________________________________________________________________
Do you have any medical condition and/ or mental disorder? Yes No Are you happy with the level of support you receive from your course tutor/ lecturer or
If yes, specify__________________________________________________________ supervisor/employer? Yes No
If no, specify___________________________________________________________
Are you currently taking any prescribed or off- the counter medication?
Yes No If yes, specify____________________________________________ Do you currently consume alcohol? Yes No
If yes, what, how much and how often_______________________________________
Are you currently having suicide thoughts? Yes No
Do you currently use drugs recreationally? Yes No
Have you ever attempted committing suicide? Yes No
If yes, specify__________________________________________________________ If yes, what, how much and how often ______________________________________

Do you have any concerns about your present use of alcohol and/ or drugs?
Have you ever engaged in self-harming behaviour? Yes No
Yes No If yes, specify_________________________________________
If yes, specify__________________________________________________________
Do you believe there is any relationship between your alcohol/ drugs use and your
Does anyone in your family have any mental health problems? Yes No current concerns? Yes No
Where were you born? _______________ Where did you grow up?_______________ Does anyone in your family have any problems with alcohol and/or drugs?
_ Yes No
Who were your primary care provider? ______________________________________
DECLARATION: The information given by ______________________________ is
Have you ever experienced any type of abuse? Yes No correct and this is for the counselling purpose only.

If yes, specify_____________________________________________________ Client’s Signature: ___________________________ Date: _______________________