OUR CURRENT WAIT TIME FOR AN ASSESSMENT SESSION IS 4-8 WEEKS WITH A SUBSQUENT 2-4 WEEK WAIT FOR CHILD APPOINTMENTS.

Registration Details Counselling

Who would you like to register for counselling?

How did you find out about the NCCG?

Note: you do not require a referral to see our counsellors

Name of person/organistion who referred you (if applicable)

About You

First Name

Last Name

Date of birth

DD/MM/YYYY

Country of Birth

Sex assigned at birth

Gender Identity

Aboriginal / Torres Strait

Language spoken at home

Contact Details

Preferred Phone

Home

Work

Mobile Phone

Email

Street number and name

Suburb / City

State

Zip/Postal Code

Brief History

Are you looking for counselling because a loved one has died? or because they have had a terminal diagnosis?

Terminal Illness

Deceased

Name of person with terminal illness

Name of person who has died

Person deceased or with teminal illness' relationship with you

Cause of death or terminal prognosis

Additional details for cause of death or terminal prognosis

Date the person died

DD/MM/YYYY

Details Of Children

Child First Name

Child Last Name

Child's Sex at Birth

Child Date of Birth

DD/MM/YYYY

Child's Gender Identity (Optional)

Medical Conditions / Allergies

Emergency Contact Details

Name of Emergency Contact

Emergency Contact Phone

Emergency Contact relationship to you

Any other information

Any Additional Information you would like to share at this stage

Company Name

Contact Information