Welcome Name * First Name Last Name Email * Date of Birth MM DD YYYY Gender Pronouns Ethnicity/Cultural Identity Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### How did you hear about me? Talking Works Psychology Today Family / friend Employer provided service Health provider (e.g. your doctor) Other G.P. (Doctor) Contact Details Emergency Contact Name * First Name Last Name Emergency Contact Phone (###) ### #### What has brought you to counselling? Contract * Fee $140+GST per 1 hour session Payment Payment by bank transfer. I will send you an invoice after the appointment with online banking details. Cash is also accepted. Cancellations 48 hours notice is required for cancellation or postponement of an appointment. Otherwise, the normal fee applies (except in some emergency situations, or if the appointment can be rescheduled on the same or following day). Sometimes situations arise which are beyond your control, in which case, let me know. I Agree Thank you.I look forward to seeing you soon.