OutLine counselling referral request

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
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
Name

First Name Last Name
Full name *
Note: this is the name OutLine will use while working with you. There may be instances when interfacing with other services where we later have to ask for 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? *
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.
Name of Adult Contact *

First Name Last Name
Relationship to young person *
Email of Adult Contact
example@example.com
Phone Number of Adult Contact

Area Code Phone Number
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
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!
Should be Empty:

OutLine counselling referral request

Adult contact person