Request of Services
Please use this form to submit all requests for counselling services.
For other inquiries, email us at email@example.com.
The following information on this form is populated into our electronic waitlist which is accessed by all counsellors at Living Well. Our counsellors are bound by confidentiality polices that prevent disclosure of any client information to external persons of organisations or institutions except under certain circumstances of imminent risk of harm to a person or child, or awareness of a serious offence. Our full Confidentiality Policy is available upon request. Should further information be required, or you wish to discuss sensitive information without entering it into our Request of Services form, please indicate this below or contact our office and ask to speak to the Triage Counsellor.
Completing the following fields will help us process and triage your referral appropriately.
Please note that all fields marked with an asterisk (*) are required.