COUNSELLING

support

Counselling will be offered telephonically, or via a secure online platform, as we know mobility, and getting around is often challenging for many of our families.

various counselling is available

Grief / bereavement
Relationships
Work related challenges
Child counselling
Abuse and trauma
Crisis management
Coping skills and stress management

counselling sign up form

Patient's First Name

Patient's Last Name

Patient's Email

Patient's Contact Number

Patients' Address

Patient's Birthday

What is your Medical Diagnosis?

Background information and reasons to want to start counselling?

Are you a member of a dedicated support group?

Yes

No, but would like to be

Would you like us to place you in touch with other patients with similiar disorders/Symptoms?

Yes

Is there any other information you feel we should be aware of?

Full name of Guardian (in case of minor) / Emergency Contact

Relationship to Patient

Email for Next of Kin

Contact number of Next of Kin

Full name of Patient's primary treating doctor?

Physical Address of treating doctor

Email of treating doctor

Contact Number of treating doctor

I consent to receive counselling services from a student counsellor from the Vita Nova Counselling centre. The sessions may take place via telephone or Zoom and are confidential. Confidentiality means that everything discussed in all sessions will remain strictly between the counsellor and client. Confidentiality will not be upheld in the following circumstances: 1) If the counsellor discerns the client is a danger to themselves or others 2) For supervision purposes. In which case all identifying information about the client will be omitted. 3) If the counsellor or their notes are subpoenaed by a court.

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