Online Service Request
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What type of counselling are you asking for?
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Details
Reason you are seeking support?
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Have you ever received any support or treatment in the past? If so, briefly explain
Are you currently experiencing any thoughts of hurting yourself or anyone else, or are you experiencing any violence or abuse? If so, please explain
Do you have any concerns related to alcohol or drugs? If yes, please explain
Do you have any concerns regarding child or vulnerable adult protection?
Do you wish to be referred to the same counsellor as before?
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Name of requested counsellor
Counselor Characteristics Required
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