EmailMeForm
Oogachaga Professional Counselling
Please read the following notes before submitting the form.
1) CONFIDENTIALITY
This form will be treated as a confidential record when it is received by Oogachaga.
2) COMPLETING THE FORM
We recommend that the person receiving the counselling to complete this form, as detailed information is required. The information provided here will enable us to offer appropriate support.
3) APPOINTMENT CONFIRMATION
We will respond within 3 working days after receiving your request. Please check your inbox & spam folders.
4) COUNSELLING FEES
Counselling fee is charged as follows:
Individual session (1 person): $120 per session, approximately 60 min
Couple or family: $160 per session, approximately 90 min
If you are in financial difficulty and unable to pay the full counselling fee, please indicate at the bottom of the form.
5) WHATSAPP & EMAIL COUNSELLING
While waiting for your appointment, please consider connecting with our trained volunteers who can provide LGBTQ-affirming emotional support:
WhatsApp counselling: 8592 0609
Tuesdays & Thursdays: 7pm - 10pm;
Saturdays: 2pm - 5pm
Email counselling: CARE@oogachaga.com [daily]
Thank you so much for your patience & understanding.
Case Manager
counselling@oogachaga.com
Note: The asterisk (*) refers to mandatory fields.
Full name
*
Preferred name
(How you like to be addressed)
*
Contact number
*
Email
*
Please repeat email
Sexual orientation
*
Please select
Gay
Lesbian
Bisexual
Questioning (Unsure)
Heterosexual (Straight)
Prefer not to use labels
Other
Your current gender identity
*
Please select
Man
Woman
Transgender Man
Transgender Woman
Nonbinary
Other
Your gender pronouns
(How should we address you?)
*
He/ Him
She/ Her
They/ Them
Other
Date of birth
*
DD
/
MM
/
YYYY
Nationality
*
Ethnicity
*
Religion
*
Relationship status
*
Please select
Single
Same Sex Relationship
Opposite Sex Relationship
Same Sex Marriage / Partnership / Civil Union
Opposite Sex Marriage
Divorced / Separated
Widowed
Others
Occupation
*
Highest education level
*
Please select
Primary / Elementary
Secondary / High School
ITE / Technical / Vocational
Pre-U / Junior College
Polytechnic
University
Others
Gross monthly income
*
Please select
< $1000
$1000 - $2000
$2001 - $3000
$3001 - $4000
$4001 - $5000
> $5000
How did you know about our service? [please tick as many as you wish]
Oogachaga staff/ volunteer
Oogachaga services
Oogachaga events
Oogachaga publications
Family/ Partner
Friends
Mainstream media
Social media
Online search
Pink Dot
Other LGBTQ organisations
Other LGBTQ events
Other
ABOUT YOUR COUNSELLING NEEDS
Have you received any form of professional help before?
*
No
If yes, please state where & when
How comfortable are you with your sexual orientation/ gender identity?
*
Very comfortable
Comfortable
Uncomfortable
Very uncomfortable
Briefly describe the issue(s) you are currently seeking counselling for.
*
Accommodation/ shelter
Disability
Drug addiction
Addiction(s) - others
Elderly/ eldercare
Employment
Family-related
Gender identity
Marital
Mental health
Relationship (same sex)
Relationship (opposite sex)
School/ teens
Sexual health
Sexuality
Sexually transmitted infections (including HIV)
Violence
Others, please specify:
What type of professional counselling do you need?
*
Individual (alone) @ $120 per session
Couple (2 people) @ $160 per session
Family (2 or more people) @ $160 per session
FOR COUPLE or FAMILY COUNSELLING, please tell us more about the other people who may be attending with you:
Full name of partner/ family member
Their preferred name
(How they prefer to be addressed)
Relationship to you
Their current gender identity
Please select
Man
Woman
Transgender Man
Transgender Woman
Nonbinary
Other
Their gender pronouns
(How should we address them?)
He/ Him
She/ Her
They/ Them
Other
Their sexual orientation
Please select
Gay
Lesbian
Bisexual
Questioning (Unsure)
Heterosexual (Straight)
Prefer not to use labels
Other
Their year of birth
For additional family members attending the counselling session, please provide information here:
What is your preferred language?
*
English
Mandarin
Other
When are your available days for appointments?
[We currently have limited time slots, so will try our best to assign]
*
Weekday mornings (Mon-Fri, 10am-12pm)
Weekday afternoons (Mon-Fri, 12pm-6pm)
Weekday evenings (Mon-Fri, 6pm-8pm)
Weekends
I am in need of financial assistance and unable to pay the full counselling fee.
*
No
Yes
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).
Name
Contact number
Relationship
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.
*
I agree.
