First and last name of person filling out form

Email Address

Phone number

Write the words that describe your gender identity here e.g., female, male, non-binary, transfeminine, transmasculine

Pronouns e.g., she/her, he/him, they/them

Please describe a brief history of the problem and the reason you require counselling

Please tick and briefly describe any other relevant areas (when a box is checked a text box for further info will appear below) Please tick and briefly describe any other relevant areas (when a box is checked a text box for further info will appear below) Mental health diagnoses Trauma or abuse Self-harm / suicide Family violence Substance abuse Child protection or family services involvement Relevant court involvement Court orders

Has the person requiring counselling received any mental health diagnoses?

Has the person requiring counselling experienced any trauma or abuse?

Does the person requiring counselling engage in any self-harm or suicidal behaviours?

Has the person requiring counselling experienced family violence?

Does the person requiring counselling need assistance with any substance abuse issues?

Does the person requiring counselling (or their parent/carer) have any current court orders in place?

Does the person requiring counselling (or their parent/carer) have any relevant and ongoing court involvement?

Has the person requiring counselling (or their parent/carer) had any involvement from child protection or family services?

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