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Child Related Offence Support
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Home
About
Individual Counselling
Group Psychotherapy
Couples Counselling
Child Related Offence Support
Contact
GP Name
Clinic Name
GP email
Client Name
Client Email*
Client Phone Number*
Client DOB
Client Address
Emergency Contact Name
Emergency Contact Phone Number
Presenting Concerns (Tick all that apply)
Difficulty controlling pornography use
Compulsive sexual behaviour
Sexual acting-out impacting mental health
Online child sexual offending (e.g., accessing CSEM)
Contact child sexual offending
Intrusive or inappropriate sexual thoughts
Depression / anxiety
Trauma history
Relationship or marriage difficulties
Emotional regulation issues
Other (add text box below)
If “Other”, please specify
Risk Concerns (if any)
Relevant Mental Health History / Notes
Reason for Referral / Additional Notes
Please note: If referring a client for group treatment, the Mental Health Care Plan should be made out to Chamarette & Associates (Christabel Chamarette’s private practice) and emailed to them at cchamarette@gmail.com
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