Make A Counselling Appointment

It’s fantastic that you are reaching out for help!

Complete the form below to request a counselling appointment with Home & Family Counselling. This information will assist us to find the most suitable counsellor for you.

Only Home & Family Counselling will have access to this information. Your responses will be kept private and secure. The information will not be used for a discriminatory purpose. You can change this information in the future by emailing mteden@hfc.org.nz.

Due to high demand, Home and Family Counselling does run a waitlist. We will be in contact with you as soon as we have an appointment available. You are welcome to phone us for an update on the waitlist, or if you seek further information about our services:

- - Central Centre: Phone (09) 630 8961
  - North Shore Centre: Phone (09) 419 9853

IMPORTANT!

Do you feel concerned about your safety or the safety of your children?

Home & Family Counselling is not a crisis centre and our office opening hours vary. If anyone is in immediate danger call 111 and ask for the police. They will arrange protection and support.

If you’re in danger but it’s not safe for you to speak:

Stay silent, call 111 then push 55.
You will be put through to Police automatically.
Listen carefully to the questions and instructions from the call taker.
They will assess your call and arrange assistance for you.

OTHER SERVICES:

Suicide Crisis Helpline:

Phone 0508 828 865 (0508 TAUTOKO)

Mental Health Crisis Team:

Central Auckland – Phone 0800 800 717
North Shore – Phone 09 486 8900

COUNSELLING REQUEST FORM

Step 1 of 4

Name*

First Last

Address:*

Street Address Suburb City Postal Code Country

Email*

Enter Email Confirm Email

Daytime Phone:*

Mobile Phone:

Evening Phone:

Is it OK to say who we are when leaving a message?*

Yes

Date Of Birth*

Country of Birth*

Which ethnic group best describes you?*

Iwi*

Gender Identity*

If selected 'Other Gender' - please specify.*

Current Employment Status?*

Hidden

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Would you like a Triage Counselling Session?

Home & Family Counselling offers Triage Counselling. A Triage appointment is a 'one-off' session with a counsellor. The counsellor will be able to decide whether you need to be assigned to a permanent counsellor urgently or can wait. They will offer strategies to support you a identify other community resources that may help you.

How did you hear about us?*

Name of practice, doctor, school or community social service who referred you?

Voluntary Contribution Guidelines:*

We aim to make our counselling accessible to all, so we ask our clients to make a voluntary contribution to Home & Family Counselling for each session to help offset some of the costs of the counselling service provided. Please select your voluntary contribution level based on your Total Household Income. Note: family sessions can be up to 1.5 hours in length, and all voluntary contributions are negotiable.

Consent:*

Home & Family Counselling is interested in measuring whether changes established during counselling sessions have been sustained. We also value the opportunity to speak with clients about their experience of counselling. Would you be happy for us to contact you 6-months after completion of counselling?

I agree to be contacted post-completion of counselling?

Please provide details of the other adults (over 16yrs) who will participate in the counselling session(s).*

First Name

Surname

Gender

Relationship (e.g. son, sibling, ex-partner)

Mobile

Ethnicity

Iwi Affiliation

Country of Birth

Date Of Birth

Voluntary Contribution Guidelines:*

We aim to make our counselling accessible to all, so we ask our clients to make a voluntary contribution for each session towards Home & Family Counselling to help offset some of the costs of the counselling service provided. Please select your voluntary contribution level based on your Household Income.

Consent:*

We both agree to be contacted post-completion of counselling?

Adult Family Member Details:

Please provide details of the other adults (over 18yrs) who will participate in the counselling session(s).

First Name

Surname

Gender

Relationship (e.g. ex-partner, son, sibling)

Mobile

Ethnicity

Iwi (if applicable)

Country of Birth

Date Of Birth

Details of Children:

Please list all the details of the children participating in the counselling session(s).

Child's First Name

Child's Surname

Gender

Date of Birth

Mothers Name

Fathers Name

Step-parent | Guardian Name

Living With?

Are all parents / caregivers aware of this referral being made for the child/children?*

Voluntary Contribution Guidelines:*

Consent:*

I agree to be contacted post-completion of counselling?

Name

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

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Make A Counselling Appointment

Make A Counselling Appointment

It’s fantastic that you are reaching out for help!

IMPORTANT!

Do you feel concerned about your safety or the safety of your children?

If you’re in danger but it’s not safe for you to speak:

OTHER SERVICES:

COUNSELLING REQUEST FORM

Your Counselling Requirements:

IMPORTANT:

Section Break

Adult Family Member Details:

Details of Children: