Glory City Church

Information about yourself

First Name

Last Name

Gender

Male

Female

Date of Birth

Marital Status

Email

Phone Number

Address

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

First Name

Last Name

Contact Number

Relationship to client

How did you find out about us?

Referral First Name

Referral Last Name

Referral Phone Number

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?

Have you had any previous counselling?

What issues are you wanting to address in Counselling?

Fee Structure

Individual Counselling $80
Couples Counselling $120
Family Counselling $120

Pay with Card

Deposit Amount: $20

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

Book Appointment