• Women Support & Counselling Service

    Please complete before our consultation. If there are questions please contact us via email or phone at counselling@planetmercy.org or 07877475664
  •  - -Pick a Date
  • Contact Information

  • Local Emergency Contact

  • Health Information and History

  • Been diagnosed by a psychologist or psychiatrist with a ‘mental illness’ or DSM disorder (such as major depression, borderline personality disorder, etc.)? Is so what was the
    diagnosis

  •  
  •  - -Pick a Date
  • Thanks for taking the time to complete this intake form.

  • Should be Empty: