Counselling Enquiry Form - Adults Wellness Centre

Counselling Contact Form

First Name

Last Name

Telephone

Gender:

Please briefly describe what has brought you to seek counselling (only share what you feel comfortable with):

Counsellor preference:

I am happy to be assigned to any available counsellor

I would prefer a male counsellor

I would prefer a female counsellor

I would like to work with a specific counsellor (please select below)

I only want to work with:

Please list your availability for sessions (e.g. daytime/evening and which day/s of the week suit):

Communication preference:

Please email me with available appointment times

Please call me to discuss before booking

Please check your spam or junk folder in case our reply email has been filtered there

I understand that The Adults’ Wellness Centre is a private clinic

I consent to having this website store my submitted information so they can respond to my inquiry