Service Request Form

Your Information

First name

Last name

Home phone number

Handphone number

Is it OK for me to leave a voicemail or text on this number? Are there any restrictions to using this number?

Email address

Date of birth

Counselling & Health History

Main issue/s you would like to explore in counselling

Work Personal Family Health Social Others

Others (please state briefly if possible):

How long have you been experiencing current difficulties?

Have you had any previous counselling or had any other type of professional support with mental or emotional health issues?

Yes No

If yes, please give me some more details such as how long ago and what kind of counselling / support it was (if you know) and whether you believed was helpful to you?

Have you self-harmed in the last 3 months?

Yes No

Have you felt suicidal in the last 3 months?

Yes No

Are you currently taking any prescribed medication for mental health issues?

Yes No

If so, can you please say what that is and what dosage you are taking.

Service Request Form

Emergency Assistance

Your Information

Counselling & Health History

Emergency Assistance