Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Erongo
Hardap
ǁKaras (Karas)
Kavango East
Kavango West
Khomas
Kunene
Ohangwena
Omaheke
Omusati
Oshana
Oshikoto
Otjozondjupa
Zambezi
State
Zip Code
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Occupation
*
Marital Status
*
Single
Married
Divorced
Widowed
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Please briefly describe the condition or health problem, if you feel comfortable sharing.
Please briefly describe, if relevant.
If you feel comfortable, please share any relevant details.
Have you ever received any previous counselling? Give details.
Please share any relevant information you feel comfortable providing.
Please list the medication names, if known, and any relevant information you wish to share.
Please briefly describe the type of support you received and whether there is anything from that experience you would like your counsellor to know.
What brings you to counselling at this time?
What would you like counselling to help you with?
If you feel comfortable, please share a brief description. You do not need to provide details you are not ready to discuss.
Have you or someone in your family experienced difficulties with alcohol or other substances that you feel are relevant to your counselling?
Save
Submit
Should be Empty: