Self referral Counselling or Coaching intake form

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Confidential service request to tania.gorry@wholewarriorsolutions.com.au
www.wholewarriorsolutions.com.au

Email *

Date *

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Service requested & consent *

I would like a callback to answer my questions

I would like to engage in counselling

I'm interested in doing Workshop/s and or training

I would like to engage life coaching

NDIS Psychosocial Recovery Coaching

Support coordination

I'd like to engage a DisAbility Support Worker

I agree Whole Warrior Solutions can collect some personal information according to the Privacy Act.

I acknowledge mandatory reporting laws & limits of confidentiality ie risk of harm to myself or others

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