Counselling Inquiry Form

Counselling Inquiry

Details of person making the inquiry
Full Name*

First NameLast Name
E-mail*
example@example.com.au
Phone Number
Please enter a valid phone number.
Organisation:
If applicable
Relationship to the Person Seeking Counselling:
How did you hear about us:

Used Bridging the Gap's services previouslyWord of mouth - at schoolWord of mouth - a health professionalWord of mouth - otherHeard about Bridging the Gap on the radioOther

Details of the person for counselling
Full Name:*

First NameLast Name
Counselling Type:*
Date of Birth:

DayMonthYear
Date as dd/MM/YYYY
Postcode:
Brief description of why counselling is sought:

Availability preferences
Days of the week available

TuesdayWednesdayThursday
Time of Day

Late morningEarly afternoonAfter school

Submit
Bridging the Gap Sydney West Inc | ABN 85 544 766 376

Our Privacy Policy can be viewed on our website at btg.org.au/privacy.

Our office days are Tuesday to Thursday during school term. We will endevour to respond to your on our next office day.
Please verify that you are human*
Should be Empty: