Face to face counselling referral request

Face to face counselling referral request
OUTLine NZ 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 danger.

In person sessions are available in central Auckland and Wellington, 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 $100 to $60 dependant on ability to pay, and in some cases are able to support your application to WINZ Disability Allowance to cover the cost of sessions.
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.
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.
Preferred pronouns?
E.g. she/her, he/him, they/them
Location *

Auckland Wellington Other option
Do you have access to Skype?

Yes No
How old are you? *
How do you describe your sexuality?
E.g. lesbian, gay, bisexual, pansexual, queer, asexual, questioning.
How do you describe your gender?
E.g. female, male, cisgender female, transgender, genderqueer, non binary. OUTLine asks about your sexuality and gender so that we can best pair you with one of our available counsellors.
Do you have an intersex condition? *

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
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 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 phone number or email address is required before you can submit this request!
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