Enquiry Form
Section 1: What is the enquiry for?
Select all that apply:
*
Adult Counselling
Child/Teen Counselling
Parent Support
Workshop/Training Delivery
Section 2: Contact / Parent-Carer Details (to be completed for all enquiries – if adult, this is your own info; if child/teen, this is parent/carer info)
Name
*
First Name
Last Name
Relationship to child/young person (if applicable):
Contact Number
*
Email Address
*
Section 3: Client/Young Person’s Details (only complete if referral is for a child/teen)
Name
First Name
Last Name
Age:
School Year:
Gender (optional):
Preferred Pronouns (optional):
Is the young person aware of the referral?:
Yes
No
Section 4: Appointment Preferences
Preferred Appointment Time (Select all that apply):
*
Morning (9.30am - 12pm)
Afternoon (12pm - 4pm)
Evening (4pm - 7pm)
Additional information (optional):
Preferred day (select all that apply):
Monday
Tuesday
Wednesday
Thursday
No preference
Preferred Type of Therapy (select all that apply):
*
In-person
Online
Preferred appointment frequency:
*
Weekly
Fortnightly
Monthly
Other
Do you have a preference for sessions to be held at the same day and time each week/fortnight?
*
Yes
No
Are you seeking short-term or longer-term support
*
Short-term
Long-term
Single session
Unsure
Any accessibility needs?
Section 5: Reason for Enquiry
What are the main concerns or reasons you are seeking support at this time?
*
Section 6: How did you hear about The Healing Space?
*
Psychology Today
BACP Directory
Counselling Directory
Creative Counsellors
Instagram
Facebook
Recommendation/Word of mouth
Other
Please provide details for 'recommendation' or 'other':
Submit
Should be Empty: