Online Service Request
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Company/School Name
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Email
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First Name
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Last Name
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Gender:
Date of Birth:
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Address
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Participant’s primary language?:
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?:
Name of requested counsellor:
May we contact you via your listed email address or phone number and leave a message?:
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