PROCARE — Counselling Booking Form

Please provide info and preferences below

Your name

First Name

Last Name

Is the booking for

Yourself

Someone else

If for someone else, provide Name and Contact Number

Reason for counselling

Optional

1. Counselling Method

2. Payment Options

You will be informed of the applicable fee

Employer will pay

Self Payment

If Employer will pay, please provide Employer / Oganisation name

If face-to-face counselling is required, please list 3 areas accessible to you.

Town and Suburb.

4. Preferred Language for counselling

Your Contact details

Phone number

Best time to phone:

E-mail address:

Message

Please note that we usually respond within 24 hours during the week and on the first working day following a weekend or public holiday.

Urgency