Please note that we will review direct referrals from individuals seeking support themselves, or when the referral is for a child.

Name

First Name

Last Name

Subject

**Please also respond below:

Where are you? (NOTE: ACC spaces available for Tauranga only. All other locations FULL)

Age

Gender

Are you seeking ACC funded sessions? (NOTE. We have limited space in Tauranga, all other locations are FULL)

If yes, have you had ACC support for sessions before?

If yes, do you have an accepted claim?

Current risk?

If you are at immediate or imminent risk, from yourself, others, or towards others: Ring 111 or Attend ED.

What professional would you like to work with?

Name of professional; Female/ Male/ Either; Clinical Psychologist/ Psychologist/ Counsellor/ Social Worker/ No preference; Experience in CBT, DBT, EMDR, IFS, ACT, Narrative, Somatic, etc.

What are you needing to work on?

For example: Low mood, anxiety, panic, addictions, nightmares, sleep and/or eating pattern, relationships, low self-worth, suicidality, non suicidal self-harm, hearing voices, etc