Counselling Enquiry Form

The NCCG provides specialist counselling and care services to support bereaved children and adults with their grief. We provide a place of safety and understanding, where bereaved people can learn about their grief and build their resilience and coping skills to help them live their own best life.

Services for children and families
All new child and family clients begin with an assessment session for a parent or caregiver with one of our counsellors. This session helps us understand your family’s personal circumstances and how the NCCG may best be able to support you.
Note: Assessment sessions require a co-payment of $190.00 from the client and are also partly funded by community donations. The NCCG’s services are not covered by Medicare.

Following this initial assessment session bereaved children aged 3-17 years can access free, unlimited individual counselling sessions (as well as group programs and adventure camps at the discretion of their NCCG counsellor).
Note: All services for children 3-17 years are provided free of charge, funded by community donations from generous supporters of the NCCG.

Bereaved parents, carers and adult children 18 years and older can access individual counselling sessions with our specialist team for a fee.
Note: All adult counselling sessions require a co-payment of $190.00 from the client and are also partly funded by community donations. The NCCG’s services are not covered by Medicare.

Services for independent adults
Bereaved independent adults are also welcomed to the NCCG. Parents and carers can also attend the centre even if their children are not attending. Our team includes staff who specialise in bereavement care for adults. Bereaved adults can access unlimited individual counselling sessions with our specialist team.
Note: All adult counselling sessions require a co-payment of $190.00 from the client and are also partly funded by community donations. The NCCG’s services are not covered by Medicare.

Sessions have a duration of approximately 2 hours and can be conducted in person at our centre in Hornsby or online via Zoom. Sessions with children include some time for consultation with the parent/carer, so we can support your child collaboratively.

If you are ready to register, please complete the form below. Once you have submitted the form, we will consider your application and be in contact with you.

Please understand that completing the registration form is only the first step in this process. Each application is assessed by our Clinical Director to determine if our service is appropriate for your needs. We cannot guarantee we can offer you counselling until we have received your enquiry and considered your requirements.

We aim to provide you and your family with comfort, care and support. If you have any difficulty with the form or would prefer to complete the form over the phone with us, please call 1300 654 556 between 9.00 am and 5.00 pm from Monday – Friday.

If you require emergency assistance you should call 000 or Lifeline on 13 11 14.

The NCCG will hold the information you provide in the registration form in accordance with the terms of our Privacy Policy.

Who would you like to register for counselling?(Required)

Your First Name(Required)

Your Last Name(Required)

How did you find out about the NCCG?(Required)

Name of person/organisation who referred you (if applicable)

Note: you do not require a referral to see our counsellors.

Contact Details

Preferred Phone(Required)

Mobile Phone Number(Required)

Home Phone Number(Required)

Work Phone Number(Required)

Email(Required)

Address 1(Required)

Address 2

Suburb/City(Required)

State(Required)

Zip/Postal Code(Required)

About You

Date of Birth(Required)

Country of Birth(Required)

Sex assigned at birth(Required)

Gender Identity(Required)

Do you identify as Aboriginal or Torres Strait Islander?(Required)

Yes

Language spoken at home(Required)

Brief History

Are you looking for counselling because a loved one has died? or because they have had a terminal diagnosis?(Required)

Terminal Illness

Deceased

Name of person with terminal illness(Required)

Person with terminal illness' relationship to you(Required)

Name of person who has died(Required)

Deceased person's relationship to you(Required)

Date the person died(Required)

Cause of Death or terminal prognosis(Required)

About the child/children

How many children require counselling?

1st Child's First Name and Last Name(Required)

1st Child's Date of Birth(Required)

1st Child's Medical condition(s)/Allergies

1st Child's Sex (assigned at birth)(Required)

1st Child's Gender Identity

2nd Child's First Name and Last Name

2nd Child's Date of Birth

2nd Child's Medical Condition(s)/Allergies

2nd Child's Sex (assigned at birth)

2nd Child's Gender Identity

3rd Child's First Name and Last Name

3rd Child's Date of Birth

3rd Child's Medical Condition(s)/Allergies

3rd Child's Sex (assigned at birth)

3rd Child's Gender Identity

4th Child's First Name and Last Name

4th Child's Date of Birth

4th Child's Medical Condition(s)/Allergies

4th Child's Sex (assigned at birth)

4th Child's Gender Identity

5th Child's First Name and Last Name

5th Child's Date of Birth

5th Child's Medical Condition(s)/Allergies

5th Child's Sex (assigned at birth)

5th Child's Gender Identity

6th Child's First Name and Last Name

6th Child's Date of Birth

6th Child's Medical Condition(s)/Allergies

6th Child's Sex (assigned at birth)

6th Child's Gender Identity

Emergency Contact Details

Name of Emergency Contact and their relationship to you(Required)

Emergency Contact's Phone Number(Required)

Any other information

Any other additional information you would like to share at this stage. If you have more than 6 children, please enter their details here too.

This field is for validation purposes and should be left unchanged.

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Counselling Enquiry Form