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Client Information

Information about yourself

First Name

Last Name

Address

Phone/Mobile

Contact Time

Daytime

After Hours

Date of Birth

Gender

Male

Female

Marital Status

Emergency Contact Details

Someone you wish for us to contact if you are in an emergency

First Name

Last Name

Contact Number

Relationship to client

Referral Information

How did you find out about us?

Referral First Name

Referral Last Name

Referral Phone/Mobile

Other Information

Complete as appropriate

Child 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?

Counselling

Have 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 Deposit

Fee Structure

Individual Counselling $80
Couples Counselling $120
Family Counselling $120

Pay with Card

Deposit Amount: $20.00

(This is a processing fee. This amount will be subtracted from the final total.)

Start your journey with us today!

Client Information

Emergency Contact Details

Referral Information

Other Information

Counselling

Pay Deposit

Client Information

Emergency Contact Details

Referral Information

Other Information

Counselling

Pay Deposit