Contact us

info@emergetherapycounselling.com
0403 840 645

Mondays 9.30am - 6pm

Located within Amanda Rawson, Clinical Hypnotherapy, shop 7 / 137 Princes Highway, Ulladulla, NSW 2539

Fill out our Intake and Registration form below and we will place you on our waitlist.

This allows us to make sure we are the appropriate service to meet your needs and to get to know some more about you prior to your appointment with us.

Name

First Name

Last Name

Phone

(###)

###

####

What service are you interested in?

For Children/ Young People's Counselling

Do you have the support and permission of the other parent? This is required and I will also need the name, phone number and address of the other parent.

Name of the Child / Young Person:

First Name

Last Name

Date of birth of Child / Young Person:

YYYY

Has prospective client been diagnosed with a Mental Health Condition previously?

Please provide details here:

Please provide a brief summary of what has bought you to counselling:

Only if you feel safe to share some brief points here. We will discuss the rest in our session.

Can you think of something you would like to achieve in counselling?

Please add them here:

Details of other supports:

Sometimes you may be linked in with other services and professionals. It would be great to know about them here.