Reach Out to Us (Confidential)

Our initial understanding of your situation depends on how much you are prepared to share with us. Please share as if you were explaining to someone who does not know you and has no information on your situation. This helps us to understand your situation a bit better so that we can communicate with you as relevantly and helpfully as we can.

We encourage you to take the time to share with us some outline information that will help us to understand your situation and respond back to you. Please try to avoid giving just 'yes' or 'no' answers. This is an opportunity to share with us so that we understand. We're listening and taking you seriously!

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Please read the terms and conditions before reaching out to us.

Your Name *

Street Address

City *

Province / State

Country *

E-Mail Address *

Telephone Number *

What’s up? Please tell us.

What’s the cause of the emotional pain you’re feeling deep inside? (If you don’t know, that’s ok)

Are you aware of any addictions you may have? Could you share with us?

Do you struggle with self-harm?

Have you visited your doctor recently?

Are you on any medications? If so, please share with us.

Have you had or are you having professional counselling or psychotherapy? Please also let us know if you are currently having these sessions.

Who do you have around you in terms of support, family, and friends? Please describe what this all looks like to you.

Please share any other information you feel would be helpful to us in understanding your situation.

Use of the Your Life Counts online submission form confirms your acceptance of these terms and conditions. If you do not agree, please do not submit this form to us. The information you give is confidential between you and YLC. We need this information to be able to assess your situation and determine whether we are a good fit for your support needs just now or whether we need to refer you to a partner agency with more experience/ specialism in your situation.
You agree to YLC responding / communicating with you via email.

Terms and agreement *

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