Let’s work together Name * First Name Last Name Email * Phone * (###) ### #### What services are you interested in? Child/Teen $170/55 minutes Individual $170/55 minutes Couple $190/55 minutes Why are you seeking counselling? Anxiety Mood Relationship/s Stress and overwhelm Parenting challenges Emotion management Confidence/self-esteem Addiction Grief and Loss Tough transition I'm not sure Other (please provide details in message) What kind of counselling are you after? In person Online Which is your preferred location? Petersham Camperdown Online Which is your preferred day? Monday Wednesday Friday Saturday What times work best for you? Mornings only Afternoons only Evenings only Flexible It depends on which day How did you hear about Sydney Counselling Space? Internet search Social media Referral Message * Thank you! We’ll be in touch with you shortly.