Oogachaga Counselling Request Form
This form is to be treated as a confidential record when it has been completed and submitted to Oogachaga.
We recommend that the person receiving the counselling to fill in this form, as detailed information is required. The information provided here will enable the Counsellor to prepare to meet you and offer appropriate support.
You will be contacted within the next 3 to 5 working days with further details about your counselling request. Please check your email message inbox or spam folder.
If you do not hear from us after 1 week, please contact us directly by phone or email.
tel: 6224 9373 (call Mon-Fri: 11am-6pm)
Note: The asterisk (*) refers to mandatory fields.
Please repeat email
Prefer not to use labels
Your current gender identity
How should we address you?
Date of birth
Same Sex Relationship
Opposite Sex Relationship
Same Sex Marriage / Partnership / Civil Union
Opposite Sex Marriage
Divorced / Separated
Highest education level
Primary / Elementary
Secondary / High School
ITE / Technical / Vocational
Pre-U / Junior College
Gross monthly income
$1000 - $2000
$2001 - $3000
$3001 - $4000
$4001 - $5000
How did you know about our service?
OC staff / volunteer
Family / Significant others
About your counselling needs
How comfortable are you with your sexual orientation/ gender identity?
Have you received any form of professional help before?
If yes, please state where and when
Briefly describe the issue(s) you are currently seeking counselling for.
Addiction(s) - others
Relationship (same sex)
Relationship (opposite sex)
Sexually transmitted infections (including HIV)
Others, please specify:
What type of counselling do you need?
For couple or family counselling services, please tell us more about the other people who may be attending with you:
Full name of partner/ family member
Relationship to you
Their current gender identity
Their year of birth
For additional family members attending the counselling session, please provide information here:
What is your preferred language?
When are your available days for appointments?
(Please tick as many as applicable, & we'll try our best to schedule)
Is there anything else you would like us to know about you or your request?
Contact details of next-of-kin / person to contact in case of emergency (optional).
By submitting this form, I give my consent for Oogachaga to collect, use and disclose the information for confidential and non-commercial purposes only, in accordance with the Personal Data Protection Act 2012.