OutLine counselling referral request

OutLine Aotearoa offers a face to face counselling service that is affirming of diverse sexuality and gender identities.

Please note - this is not a crisis or emergency counselling service. If you need help now, call 1737 to talk to a trained counsellor. Always dial 111 if you (or someone else) is in immediate danger.

In-person sessions are available in central Auckland, with Skype and other options available nationally. Find out more about OutLine's counselling services on our website.

As part of assessing your referral, OutLine will discuss with you payment for services. We have a scale from $80 to $120 dependant on ability to pay, and in some cases are able to support your application to Work and Income Disability Allowance to cover the cost of sessions.

You can indicate what funding support you might need as part of this referral form.

Are you completing this referral for yourself, or for someone else? *

For myself For someone else

Please tell us your name, and relationship to the person being referred for counselling.

E.g. parent, phone volunteer, or other professional working with the client.

Does this person know that you are referring them?

Yes No

Please complete the rest of this form as though you are the person to be referred for counselling.

Name (legal name please) *

First Name Last Name

Preferred name?

Note: While OutLine is able to use preferred names at all times while working with you, there may be instances, such as when applying to WINZ, where we need to know your legal name.

Pronouns

E.g. she/her, he/him, they/them

Location *

Auckland

Do you have access to Skype?

Yes No

How old are you? *

How do you describe your sexuality?

E.g. lesbian, gay, takatāpui, bisexual, pansexual, queer, asexual, questioning.

How do you describe your gender?

E.g. Trans femme, trans masc, nonbinary, genderqueer, cisgender man, cisgender woman, fa'afafine, takatāpui, tāne, wahine, questioning... OutLine asks about your sexuality and gender so that we can best pair you with one of our available counsellors. It's okay if you would rather not say, or you're not sure.

Do you have an intersex variation?

Yes No Prefer not to say Don't know I don't understand the question

What is your phone number?

Home phone, mobile or both!

Can we leave a voicemail if you don't answer?

Yes No

What is your email address?

How would you prefer we contacted you? *

Phone Email

Do you require an interpreter (i.e. English is not your preferred language, or require a sign interpreter)? *

Yes No

Tell us more about your interpreter requirements

Payment for counselling is based on a sliding scale fee ($80-$120 per hour), what is your preferred payment rate? (Note that if you are unable to afford $80, the next question asks about financial support options)

80 90 100 110 120

Do you need financial support to afford our counselling services? If so, please let us know what support you might need to use. We can support you through this process and also discuss this further with you as part of the referral process.

WINZ Student loan Partial subsidy via OutLine Covid response funding (paying $10-70 range) Full subsidy via OutLine Covid response funding (unable to pay otherwise)

Anything else we need to know about contacting you?

I.e. hours we shouldn't call, or not to leave a message if someone else answers the phone.

Do you have any concerns about your own safety, or the safety of others? *

Yes No

Please note - this is not a crisis or emergency counselling service. If you need help now, call 1737 to talk to a trained counsellor. Always dial 111 if you (or someone else) is in immediate danger.

Emergency contact

Note that as part of the assessment before starting counselling, we'll need contact details for an emergency contact person for you.

Note that you'll need to provide either a phone number or email address before you can submit this request!