Supervision Registration Form

Client Name *

First

Last

Date of Birth *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How did you hear about me? *

Phone (What's App) *

Email *

Emergency Contact Name *

First

Last

Emergency Contact Relationship: *

Emergency Contact Phone *

Occupation *

Relevant mental health and/or counselling history: *

Current Medications/ Illnesses: *

Current Supports: (people/places/strategies etc): *

Preferred Outcomes/Expectations: *

If you are experiencing a crisis and need urgent support please call:

Australia

Lifeline 13 11 14 or Beyond Blue 1300 22 4636

New Zealand

Lifeline 0800 543 354, Suicide Crisis Helpline 0508 828 865, Samaritans 0880 726 666

Singapore

Samaritans of Singapore 1800–221 4444

Hong Kong

The Samaritans: 2896 0000, Suicide Prevention Service: 2382 0000

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