This form is for us to get the necessary information about you, so we can match you to a counsellor best suited for you. (The information provided here is treated with utmost privacy).
Please only fill this form if you are the (we do not accept referrals, you are unable to fill this form on behalf of someone else).
Our services serve to deescalate, counsel and when necessary, refer you to specialist facilities. Your counsellor will work with you to provide psychological first aid counselling and might refer you to mental health facilities for further evaluation and treatment by mental health specialists.
Note that by filling and submitting this form, you agree to the set out terms and conditions of our service provision.