First Time Booking

This is a secure form. Your confidentiality is respected and protected at all times. No identifying information is stored on my computer, or shared with third parties.

Full Name

Briefly, what brings you to counselling? What would you like to get out of these sessions?

When would you like to come?

Have you been to counselling before?

Yes

If you are currently receiving support from a psychiatrist or mental health service, please provide the name of your psychiatrist or clinician (if applicable)

How did you hear about Avondale Counselling?

Contact Information

Mobile or Landline

The following two questions are required as a safety requirement in case of emergency.

Address

Date of Birth

Day

Month

Year

If you have not done so already, please read the Terms and Conditions of Counselling.: I will assume you have read these and are happy to proceed.