Oogachaga Counselling Request Form
This form is to be treated as a confidential record when it has been completed and submitted to Oogachaga.
2) Filling in 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 the Counsellor to prepare to meet you and offer appropriate support.
3) Limited appointment slots
We currently have limited slots available for new appointments, mostly on weekday afternoons. There may not be many weekday evening & weekend slots available. We apologise in advance, and appreciate your kind understanding on this.
tel: 6224 9373 (call Mon-Fri: 11am-7pm)
Note: The asterisk (*) refers to mandatory fields.
(How you like to be addressed)
Please repeat email
Prefer not to use labels
Your current gender identity
Your gender pronouns
(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
Their preferred name
(How they prefer to be addressed)
Relationship to you
Their current gender identity
Their gender pronouns
(How should we address them?)
Their sexual orientation
Prefer not to use labels
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?
[We will try our best to assign, as we currently have limited time slots.]
I am not available at these times (& open to exploring other counselling services)
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.