Please enable JavaScript in your browser to complete this form.Email Counselling Booking Form - New ClientsExisting Client *I confirm that I am a new clientName *FirstLastEmail address *EmailConfirm EmailEncrypted Email Address (if you will be using one for email counselling)EmailConfirm EmailIt is preferred that you used an encrypted email address to protect your privacy and data. A free Protonmail or Hushmail email account would be ideal.Suitability for Email CounsellingPlease note that email counselling may not be suitable for all people. If you are experiencing interpersonal violence of any kind (whether physical, emotional, sexual, spiritual or financial), please reach out by phone on 0411 889 175 and alternative arrangements will be made to ensure you get the help you need. Similarly, if you are having any thoughts of self-harm or significant mental health challenges, email counselling may not be suitable for you. I encourage you to contact me on 0411 889 175 or by email so alternative arrangments can be made.Informed ConsentIf you decide to proceed with email counselling, I ask you to read, sign and submit the counselling agreement, which you will be directed to after submitting this form. This is an important step in clarifying that you understand the arrangments for email counselling. It is important to me because I value your right to give informed consent to receive email counselling.Intake Form for New ClientsWhat is the main issue you are wanting help with?Have you had counselling previously? *YesNoWhat was the issue you sought treatment for?What did you find helpful, or not helpful, about your former counselling?Are you currently receiving treatment from another mental health provider?YesNoPlease advise what you are receiving therapy for, and if you are willing, the name of the therapist providing the treatmentAre you currently taking medication for a mental health concern?YesNoWhich medication/s are you taking?To assist me in providing you with effective email counselling, the following information is appreciated.How often do you consume alcohol?Please selectA few times a weekWeeklyOccasionallyNeverHow often do you take non-prescription drugs such as marijuana, etc.?Please selectMore than once a weekInfrequentlyNeverHow often do you take prescription drugs?Please selectMore than once a weekInfrequentlyNeverIn the last 4 weeks, about how often did you feel:... nervousPlease selectNone of the timeA little of the timeSome of the timeMost of the timeAll of the time... without hopePlease selectNone of the timeA little of the timeSome of the timeMost of the timeAll of the time ... restless or jumpyPlease selectNone of the timeA little of the timeSome of the timeMost of the timeAll of the time... that everything was an effortPlease selectNone of the timeA little of the timeSome of the timeMost of the timeAll of the time... so sad that nothing could cheer you upPlease selectNone of the timeA little of the timeSome of the timeMost of the timeAll of the timeSelf-harm and SuicideI have previously deliberately harmed or injured myselfI am currently experiencing thoughts of self-harmI have previously tried to kill myselfI am currently experiencing thoughts of wanting to kill myselfWhat are your best hopes for counselling?How many sessions would you like to book?Select Number of Sessions1 email counselling session: $503 email counselling sessions: $125 (save $25)6 email counselling sessions: $250 (save $50)Note that one "session" is equal to one email exchange of up to approximately 1000 words per emailHow to pay:Payment OptionsI would like to pay by direct bank transfer - please forward an invoiceI will pay by credit or Debit card - select option belowOnce you submit this booking form, you will be provided with your 'next steps' to get started with email counselling.Submit Email Counselling x 1 Single Session 1 session = 1 client email up to 1000 words plus 1 therapeutic response AU$50.00 Processing ... Pay NowStripe Payments requires Javascript to be supported by the browser in order to operate. Email Counselling x 3 3 Sessions Save $25 compared to the cost of 3 individual sessions AU$125.00 Processing ... Pay NowStripe Payments requires Javascript to be supported by the browser in order to operate. Email Counselling x 6 6 Sessions Save $50 compared to the cost of 6 individual sessions AU$250.00 Processing ... Pay NowStripe Payments requires Javascript to be supported by the browser in order to operate. Not Quite Ready Yet?You are welcome to book a free inquiry call to find out if we are a good match Free Inquiry Call
