Free online counselling service in South Africa

Humanitas Counselling Request

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Counselling request and consent form

First Name

Last Name

Contact Number

ID Number

Reason for Counselling

Age Declaration

Emergency Contact Name

Emergency Contact Number

Humanitas Counselling Intern

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 Training (Pty) Ltd. T/A Humanitas Training