Expression of Interest

Personal Information

Thank you for your interest in my counselling services!

Please complete this form to help me understand if we might be a good fit for working together. All information shared will be kept confidential.

Your full name

Your preferred name (if different) and pronouns (e.g. She/He/They etc.)

Your birthday

Day

Month

Year

Your contact details. Please include Email Address, Home Address, and Mobile Phone.

Identity & Background

(Please share only what you feel comfortable with)

Would you like to tell more about how you identify? (e.g. Gender identity, Sexuality, Culture, Neurodivergence, Religious/Spiritual Beliefs (if any). You may wish to include any diagnosis (including self-diagnosis).

Have you experienced trauma or challenging life experiences that you feel comfortable briefly mentioning? (e.g. an abusive relationship, sexual assault/abuse, childhood trauma, minority stress, religious/spiritual abuse etc.)

Please check the statement/s that best describe your current situation. (You can choose more than one).

I am currently safe and the challenges/symptoms I want to work on are mostly a result of past experiences.

I am currently dealing with ongoing challenges to my safety or well-being.

I'm not sure/It's complicated

Would you like to tell me more about your current situation, concerns, or symptoms? What are the challenges? How are you navigating them?

Appointment Preferences

What is your preference? Phone/Zoom/Face to Face appointments? What days and times are you available?

Next Steps

I will review your form and reach out within 2-3 business days to discuss potential next steps or provide referrals if needed. Thank you for sharing your information with me.

An important note about availability...

As an individual practitioner, I maintain a small, focused practice to ensure quality care for each client. This means I have limited availability and may not always be able to take on new clients. If I am unable to offer you a space in my practice, I will do my best to provide you with appropriate referrals to other trauma-informed practitioners or organisations who may be able to support you.

If you are currently in immediate danger, please contact emergency services (000) or visit your nearest emergency department. For 24/7 support, contact Lifeline: 13 11 14