Intake form

Name *

Email address *

What type of support are you seeking?

Please select at least one option.

Individual Counselling

Couples Counselling

Family Therapy

Group Therapy

Crisis Support

How did you hear about us?

What is your preferred method of communication?

What days are you generally available for sessions?

Please select at least one option.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Do you have any specific goals for your counselling sessions?

Which service or services are you interested in?

Please select at least one option.

Self Esteem & Self Concept

Childhood Trauma

Bereavement Support

Anxiety & Depression

Anger & Aggression

Additional questions or comments

RISE WITHIN