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Request a Counseling Session.

Tell us a little about what you need, and a counselor from our team will reach out to confirm your appointment.

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Confidential by Default

Everything you share here is treated with respect and professional confidentiality.

What Happens Next

A counselor or team member will contact you to confirm your date and time — this form only requests an appointment.

Book a Counseling Session

Please complete this short form to request a session. Your information will be treated with respect and confidentiality.

1. Client Information

Full Name

Phone Number

Email Address

Location/City

Preferred method of contact

Phone CallWhatsAppEmail

2. Counseling & Support Needs

What would you like support with? You may select more than one.

Stress, Anxiety or Excessive WorryDepression, Low Mood or Loss of InterestEmotional Distress or Difficulty CopingAnger ManagementLow Self-Esteem or Self-ConfidenceTrauma or Difficult Life ExperiencesGrief, Bereavement or LossRelationship or Marriage ChallengesFamily or Parenting ConcernsChild or Adolescent Mental HealthLoneliness or Social IsolationWork, School or Academic ChallengesSubstance Use, Abuse or AddictionRecovery and Relapse SupportSleep or Lifestyle ChallengesPersonal Growth and Self-DevelopmentOther Mental Health or Emotional Well-being ConcernsOther

Briefly tell us what you would like support with

Please share only what you are comfortable sharing.

3. Appointment Preference

Preferred session format

OnlineIn-person

Preferred Date

Preferred Time

Type of session

Individual SessionCouple/Relationship SessionFamily Session

4. Additional Information

Is this your first counseling session with NOPDER VMH?

YesNo

Is there anything else you would like the counselor to know before the session?

I understand that submitting this form is a request for an appointment and that a counselor or member of the NOPDER VMH team will contact me to confirm the date and time.

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