Counselling Request
Please complete the following so that we can assist with next steps in your counselling journey.This information is kept strictly confidential and at no point in time is your information available to anyone other than the relevant staff at CityHill Church Counselling.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Your Gender
*
Please Select
Male
Female
Prefer not to say
Other
Your Age
*
Please Select
18-25
26-35
36-45
46-55
56-65
65+
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
It’s Complicated
If this is for marriage counselling, is your partner is in agreement to the counselling and will they be attending with you?
*
Please Select
Yes
No
If applicable, please confirm the name and surname of your spouse/partner.
Spouse First Name
Spouse Last Name
Do you have any illnesses or diagnosed disorders, and if so, are you on any medication?
*
Please give us a general idea of your current situation and what you would like to achieve through counselling.
*
Have you previously been for counselling at CityHill Church or elsewhere?
*
Please Select
Yes
No
If you answered "yes" above, please confirm when and where you went for counselling and if it was successful?
Do you struggle currently with an addiction of any kind?
*
Please Select
Yes
No
If you do struggle with an addiction, please provide further details.
Our counselling hours are Monday - Thursday 08h00 - 16h00 and Fridays 08h00 and 13h00. Please confirm times and days you can make weekly one-hour sessions within these times. (The more flexible you are, the quicker it will be to assign you counsellors.)
*
Submit
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