Relationships and Couples Counselling

First Name*

Last Name*

Street Address*

Suburb*

City*

Post Code*

Country*

Email*

Mobile*

Other contact number

Is it OK to say who we are when leaving a message?*

Yes

Date of Birth*

Country of Birth*

What time of day do you prefer?

Issues to be discussed with counsellor.*

Would you like a Triage Counselling Session?

Home & Family Counselling offers Triage Counselling. A Triage appointment is a 'one-off' session with a counsellor. The counsellor will be able to decide whether you need to be assigned to a permanent counsellor urgently or can wait. They will offer strategies to support you and identify other community resources that may help you.

Would you like a Triage Counselling Session?

Yes

Please list the 'other' social service or health provider.

Name the practice, doctor, school or community social service who referred you to Home & Family Counselling?

Please provide details of the other adults (over 16yrs) who will participate in the counselling session(s).*

Voluntary Contribution Guidelines (Couples):

We aim to make our counselling accessible to all, so we ask our clients to make a voluntary contribution to Home & Family Counselling for each session to help offset some of the costs of the counselling service provided. Please select your voluntary contribution level based on your Total Household Income. Note: all voluntary contributions are negotiable.

Consent:(Couples):

Home & Family Counselling is interested in measuring whether changes established during counselling sessions have been sustained. We also value the opportunity to speak with clients about their experience of counselling. Would you be happy for us to contact you 6 months after the completion of counselling?

Agree Consent:*(Couples)

Yes - we both agree to be contacted.

No - we do not want to be contacted.