Page 1 of 2

Counseling Form

Hey there,

Thank you for taking this step for your wellbeing with Project Green Circle. This short form helps us match you with the right counselor from our team and understand what kind of support fits your needs best.

Your answers are confidential and shared only with your assigned counselor and our management team for coordination.

Once submitted, we'll reach out to guide you through next steps.

Is counseling you or someone else?

*

A

Myself

B

Family member

C

Friend

D

Colleague / Co-worker

E

Others

If this is for someone else, have they agreed to attend counseling?

A

Yes

B

Not Yet

C

No

Client's full name (the person who will attend sessions)

*

Gender

*

Age

*

Phone number

*

Email

*

Current address (City/Country)

*

Preferred communication medium

*

A

Phone

B

SMS/Text

C