Free online counselling service in South Africa
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Humanitas Counselling Request
Counselling request and consent form
First Name
Last Name
Contact Number
Email
ID Number
Reason for Counselling
Age Declaration
Select a option
I am older than 18 years of age
I am younger than 18 years
Emergency Contact Name
Emergency Contact Number
Humanitas Counselling Intern
Select a counsellor
Any Counsellor
Zenande Matunda
Katherine Jackson
Please select a Humanitas Counsellor
I understand and agree with the following statements:
I understand and acknowledge; that the person I am about to see is a Counsellor in training, working under the supervision of registered Social Workers in private practice.
I understand that confidentiality will be maintained between my counsellor and I at all times, except for the following reasons:
(1) if it is noted by my counsellor that I am a danger to myself or others.
(2) if there is any suspected child abuse, elder abuse or abuse of people with disabilities.
(3) if it is mandated by the law for legal proceedings.
I understand that if I am younger than 18 my counsellor needs written consent from both parents before being able to see me
Hereby I give consent to be counselled by a counsellor in training; under supervision of Vita Nova (Pty) Ltd. T/A Humanitas Training
The terms must be accepted to request counselling.
Submit
