Book appointment Start your journey with us today! Client InformationInformation about yourselfFirst Name Last Name Address Phone/Mobile Contact TimeDaytime After Hours Email Date of Birth Gender Male FemaleMarital Status - Select -MarriedSingleSeparatedDivorcedSingle ParentEmergency Contact DetailsSomeone you wish for us to contact if you are in an emergencyFirst Name Last Name Contact Number Relationship to client Referral InformationHow did you find out about us? - Select -Self-ReferredAgency/ church namePastoral team referralWord of mouthWeb searchReferral First Name Referral Last Name Referral Phone/Mobile Other InformationComplete as appropriateChild Safety Orders, Domestic Violence, Corrections Order? History of Mental Health Issues, Self-Harming, Substance Abuse, Addiction, Childhood Abuse or Trauma? Medications, Prescribed or Self-Medicating? Other Supporting Agencies? CounsellingHave you had any previous counselling? What issues are you wanting to address in Counselling? Where would you like to have your meeting? In Person Video CallPay DepositFee Structure Individual Counselling $80 Couples Counselling $120 Family Counselling $120Pay with CardDeposit Amount: $20.00(This is a processing fee. This amount will be subtracted from the final total.)Submit Client InformationInformation about yourselfFirst Name Last Name Address Phone/Mobile Contact TimeDaytime After Hours Email Date of Birth Gender Male FemaleMarital Status - Select -MarriedSingleSeparatedDivorcedSingle ParentEmergency Contact DetailsSomeone you wish for us to contact if you are in an emergencyFirst Name Last Name Contact Number Relationship to client Referral InformationHow did you find out about us? - Select -Self-ReferredAgency/ church namePastoral team referralWord of mouthWeb searchReferral First Name Referral Last Name Referral Phone/Mobile Other InformationComplete as appropriateChild Safety Orders, Domestic Violence, Corrections Order? History of Mental Health Issues, Self-Harming, Substance Abuse, Addiction, Childhood Abuse or Trauma? Medications, Prescribed or Self-Medicating? Other Supporting Agencies? CounsellingHave you had any previous counselling? What issues are you wanting to address in Counselling? Where would you like to have your meeting? In Person Video CallPay DepositFee Structure Individual Counselling $80 Couples Counselling $120 Family Counselling $120Pay with CardDeposit Amount: $20.00(This is a processing fee. This amount will be subtracted from the final total.)Submit "*" indicates required fields Client InformationInformation about yourselfName* First Last Address* Street Address City State ZIP / Postal Code Phone*Email* Date of birth* DD slash MM slash YYYY Gender* Male Female Marital Status*-Select-SingleMarriedSeparatedDivorcedSingle ParentEmergency Contact DetailsSomeone you wish for us to contact if you are in an emergencyName* First Last Phone*Relationship to client* Referral InformationHow did you find out about us?-Select-Self-ReferredAgency/church namePastoral team referralWord of mouthWeb searchReferral Name First Last Other InformationComplete as appropriateChild Safety Orders, Domestic Violence, Corrections Order?* History of Mental Health Issues, Self-Harming, Substance Abuse, Addiction, Childhood Abuse or Trauma?* Medications, Prescribed or Self-Medicating?* Other Supporting Agencies?* CounsellingHave you had any previous counselling?* What issues are you wanting to address in counselling?*Where would you like to have your meeting? In Person Video Call Pay DepositCoupon Credit Card* American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 CVC Cardholder Name Selah Appointment Price: Total By clicking submit you agree and adhere to our 24-hour cancellation policyNameThis field is for validation purposes and should be left unchanged.