• 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 video counselling  options (e.g. Skype, Zoom) 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 or offer alternative subsidised options.

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

    For more information about how we collect and use your personal information, including the information in this form, please refer to the OutLine Privacy Policy


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


  • Adult contact person

    For young people under 16, we also need the contact details for an appropriate adult, who we will contact alongside the young person. We want this to be someone that feels safe to have us contact, and could be a parent/guardian or health worker. Our counsellors will also need to have certain permissions from a parent/guardian of young people in this age group. 
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  • 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!

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