Request an appointment

Are you filling in this form for yourself or on behalf of someone else? *

Please note that minors under 18 will require parental consent to attend counselling sessions.

For myself

For my child (under 18)

I'm referring a client

For myself and my partner

For myself and my family

Name *

Please submit the name of the person who will be coming in for counselling sessions.

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender Identity *

Woman

Man

Non-binary

Prefer not to say

Other

Phone *

If you are submitting on behalf of your child, please submit your own phone number

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Please let us know your preferred counsellors (select all that apply)

Please note, we endeavour to match everyone with their preferred counsellor, however in cases where a counsellor's waitlist is too long or their working days don't suit, we will recommend other options for you.

Anna Harrison

Annette Nichols

David Legg

Frances Sullivan

Gemma Neuendorf

Ginnie Denny

Jane Mudford

Lee Beston

Nina Hawkins

Paula Turner

Riley Cook

I don't mind, please recommend one for me

Privacy Acknowledgement *

I have read and understood Northspan Wellbeing's Privacy Policy, and I agree to its terms regarding the collection, use, and storage of my personal information.