Name *
Name

House 16, Street Silver
Phnom Penh
Cambodia

+855 92 677 021

We are an inter-agency international non-profit cooperative that provides training, consultation, assessment, counseling, and opportunities for renewal to expatriates living and working in Cambodia.

         Simply put:  We are both seeking and promoting deep connection, growth, and living well.

Inquiries

Request of Services

Please use this form to submit all requests for counselling services.

For other inquiries, email us at info@livingwellcambodia.org.

CONFIDENTIALITY

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.

Date of request *
Date of request
Please provide today's date
Name *
Name
Select a range
Select one
Please select one
briefly description your reason for requesting services
The following questions assist us in understanding the urgency of your request. Please note that some questions are optional.
Have you (or the person being referred) attempted suicide or engaged in self-harm within the last 2 years?
Are you (or the person being referred) experiencing thoughts of suicide or self-harm?
Do you feel you are at risk of hurting yourself?
Do you feel you are at risk of hurting others around you?
Do you have a diagnosis of a mental illness?
I do not wish to respond to the optional questions, however, I am willing to provide the information verbally to the Triage Counsellor, if contacted. *
Have you experienced a traumatic incident within the last four months? *
Are you a current partner or with a current partnering orgaisation of Living Well? *
Please select if you are a member of one of these organizations
Select one
Use this space to provide additional info regarding services for youth, families, groups, or other requests
Availability *
Our office hours are from 9:00a - 5:00p, Monday - Friday Check all that apply Please note that more restrictive availability may result in a longer wait time before an appointment is offered. Greater availability means you are likely to be seen sooner.
Please designate preferred location for meeting with a counsellor. *Please note: Location preference is subject to counsellor availability.
Visit the "Our Team" page to learn more about our team. Counsellor preference will be considered along with counsellor availability.
If my preferred counsellor is not available for more than a month, I am happy to meet with the first available. *
Select one
ex: "before/after this date", "during the month of ______", etc.
Select one
If you selected "other," please specify any additional information
Please include any additional information that could be helpful for us to know as we process your request in a timely manner.