Client Details + Confidentiality and Therapeutic/Counselling Agreement Name(Required) First Last Preferred Name GenderPronounsDate of birth MM slash DD slash YYYY Residential Address Street Address Suburb State Post Code Postal Address PO Box Number Suburb State Post Code Phone Landline Mobile Email It is safe for Engender to contact me by: (select those that apply) Address Landline Mobile Email When is it safe for us to contact you? (days/times)Is it safe to leave a message? Yes No CommentsEmergency Contact Full Name Phone Child One Full Name Date of Birth Child Two Full Name Date of Birth Child Three Full Name Date of Birth Child Four Full Name Date of Birth Child Five Full Name Date of Birth Details of additional childrenLanguage/s spoken at homeCountry of birthDo you have a disability? Yes No Do you need any accommodations to attend an appointment?Are you an Aboriginal or Torres Strait Islander person? Yes No Do you have a Police Family Violence Order (PFVO)? Yes No When does it expire? MM slash DD slash YYYY ConditionsDo you have a Family Violence Order (FVO)? Yes No When does it expire? MM slash DD slash YYYY ConditionsChild Custody/Contact Arrangements (Select one) I have a verbal agreement I have a Parenting Plan I have a Parenting Order/Consent order (Court Order) ConditionsHow did you hear about Engender Equality?Can Engender contact you regarding research or other opportunities in the future? Yes No Therapeutic/Counselling Agreement(Required)Information about Engender Equality Therapeutic Services Engender Equality offers therapeutic services to people in Tasmania who have experienced intimate partner violence. Engender Therapeutic Services are: • Free and confidential • For people who have, or are, experiencing intimate partner violence • For people who live, or are based, in Tasmania • Available face-to-face, by phone and/or online using Zoom • 1 hour appointments (first appointments may go for longer) • Mid to long term engagements over a two-year period. Some people will only need a few sessions, some people will participate in many more • For all people over the age of 15 inclusive of gender, sexual orientation, ability, marital or socioeconomic status, cultural, religious, ethnic background and visa status • For people who identify as LGBTIQA+ who experience family violence perpetrated by intimate partners, including those in non-traditional relationship structures. Counselling is a confidential space to talk with, and be listened to by, a trained Family Violence Practitioner. Trauma-informed family violence counselling specialises in providing support around the following areas: • Family violence risk and safety planning • Understanding violence and abuse • Self-compassion, self-work and empowerment • Traumatic impacts of the family violence • Understanding your rights in a relationship • Emotional health and wellbeing • Understanding impacts of family violence on children • Connecting to additional relevant services, programs and social support networks. Engender Equality is not a crisis/emergency service. Practitioners may not be able to respond in a timely way between sessions. If you are unsafe and need immediate help, please call 000. Working together If you need to cancel or postpone an appointment, please let your practitioner know as soon as you can so we can give the time to another person. Please also inform your practitioner if you are running late to an appointment. There may be some limitations to what services Engender can offer you and this will be based on the discretion of individual practitioners and their expertise and training. In some instances, your practitioner may need to stop working with you. This may be due to a conflict of interest, poor health, or extended leave. Where possible, the practitioner will let you know that they are unable to keep working with you and you will be given the opportunity to work with an alternative Engender practitioner. If you have any feedback (positive or negative) you can email ceo@engenderequality.org.au. All feedback provided will be handled with respect, sensitivity, and confidentiality. Respectful communication Engender is committed to providing a safe environment for clients, staff and visitors. Please communicate with others respectfully at all times. Disrespectful or threatening behaviour will not be tolerated and may result in services being withdrawn. Consent to services I have discussed the therapeutic process with my practitioner and understand: • What to expect from the therapy process; • The role and responsibilities of my Engender practitioner; • My responsibilities as an Engender client; and • My options for giving feedback or making a complaint. By checking the box below, I am indicating that I have read and agree with the above statements. I agree to the Therapeutic/Counselling AgreementConfidentiality Agreement(Required)Recording and Storing Information Engender Equality is committed to the secure collection, maintenance, and disposal of your personal information throughout the therapeutic process. This will be done in ways that protect privacy and maintain confidentiality. Specifically, Engender Equality will: • Collect and keep information about clients only when it is relevant and necessary to the provision of the service; • Collect, store, and report all data required by funding arrangements within the boundaries of client confidentiality and privacy; • Ensure data about each client is up-to-date, accurate and secure, whether stored in hard copy or electronically; • Keep records only for the required length of time, and transfer or dispose of client records correctly; • Consider potential safety issues for the client and their children and make accommodations where reasonably possible; • Give clients an option to remain anonymous or use a pseudonym; • Take account of any relevant cultural or religious sensitivities of people using services in the way information about them is collected, stored, and used; and • Collect and analyse de-identified client data to inform service improvements, staff professional development, and performance management. Confidentiality and sharing information I understand that any personal information that I share throughout the therapeutic process will remain confidential, except where: • I request that an Engender staff member share my information with others and give written permission for them to do so; • Engender is ordered by a court to share my records or other information; • An Engender staff member believes there is a serious and specific risk of harm to myself or others; • An Engender staff member believes there may be harm, or risk of harm, to children. Engender is legally required to report such concerns to Strong Families Safe Kids Referral and Advice Line /Child Safety Services* • Basic information (that does not include names or identifying details) is used for supervision, reporting, education, or research purposes. I agree to the Confidentiality AgreementRequesting or sharing information: ConsentI give permission for an Engender staff member to request or share information about me or the person in my care with the agencies/people specified below when/if required: Yes No Requesting or sharing information: DetailsIf required, I give permission for an Engender staff member to request or share information about me or the person in my care with the agencies/people specified below: Any/all listed below Community Corrections Child Safety Services Strong Families Safe Kids Advice and Referral Line Tasmania Police Family Violence Counselling and Support Service Department of Health Department for Education Children and Young People Centrelink Victims of Crime Service – Department of Justice Victim Support Services (including Victims of Crime) Women’s Legal Service Legal Aid Shelter or crisis accommodation service GP or health professional Solicitor Mental health professional Other Select AllShelter or crisis accommodation service nameGP or health professional nameSolicitor nameMental health professional nameOther – nameWould you like to receive a copy of this completed form? 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