Glory City Church

Client Information

Information about yourself

First Name

Last Name

Gender

Male

Female

What is your preferred method of contact with your counsellor?

Face-to-face

Online via video call

Date of Birth

Marital Status

Email

Phone Number

Address

Emergency Contact Details

Someone you wish for us to contact if you are in an emergency

First Name

Last Name

Contact Number

Relationship to client

Referral Information

How did you find out about us?

Referral First Name

Referral Last Name

Referral Phone Number

Other Information

Complete as appropriate

Child Safety Orders, Domestic Violence, Corrections Order?

History of Mental Health Issues, Self-Harming, Substance Abuse, Addiction, Childhood Abuse or Trauma?

Medications, Prescribed or Self-Medicating?

Other Supporting Agencies?

Counselling

Have you had any previous counselling?

What issues are you wanting to address in Counselling?

Pay $20 Deposit

Fee Structure

Individual Counselling $90
Couples Counselling $150
Family Counselling $150

Pay with Card

Deposit Amount: $20

(This is a processing fee. This amount will be subtracted from the final total.)

I'd like to receive marketing materials via email and/or SMS

I have read and agree to the Confidentiality Agreement
and our Terms and Conditions