Book with us! Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Contact time * Daytime or After hours Email * Message * Phone/Mobile * Country (###) ### #### Date of Birth * Gender * Emergency Contact details * Someone you wish us to contact if you are in an emergency. First Name Last Name Contact number * Country (###) ### #### Relationship to Client * How did you find out about us? Referral information NDIS/Agency Word of mouth Web search Self -referral Other Information Complete as appropriate Domestic violence order Corrections order Child safety order Other orders History of Mental Health Self-harm Substance Abuse Addiction Child abuse/neglect Trauma Medication -Prescribed Medication -Self-medication Other Information Briefly share Counselling * Have you had any previous counselling ? What issues would you like to address? * How would you like to have your meetings? * In person Online Pay Deposit Fee structure NDIS (as pre current pricing guide) Individual counselling -$150 Group work - based on group type Supervision Mentoring/life coaching /Community connections Pay by card Enter card number Enter your details Thank you! Cancellation Policy: A cancellation fee will apply if an appointment is cancelled with less than 24 hours notice.
