ServicesBook Appointment @SelahWellnessCentre services counseling options Individual Counselling$80 Couples Counselling$120 Family Counselling$120 Book appointment First NameLast NameEmailDonation Amount $20 $30 $40 OtherPlease Provide Custom AmountDonate Now Selah Appointment "*" indicates required fieldsClient 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 FemaleMarital 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 CallPay DepositCoupon Credit Card*American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 CVC Cardholder Name Selah Appointment Price: Total NameThis field is for validation purposes and should be left unchanged.