Practitioner Partner Referral Form - Steph O'Brien Counsellor
Thanks for wanting to connect with Steph O'Brien.  

Please complete this intake form so that Steph can learn a little about you and your situation and the best way to contact you.

If you are in crisis, or you are experiencing severe mental health distress, please contact 111 emergency services or phone Te Haika on 0800 745 477 if you live in the Wellington Region.  For those outside this region find your local crisis team by visiting www.health.govt.nz/your-health/services-and-support/health-care-services/mental-health-services/crisis-assessment-teams.

If you need to speak to a trained counsellor immediately, you can text or call 1737 at any time.

Noho Ora Mai,

The Little Shadow Team

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E-post *
Your first and last name *
Your contact phone number *
Tell me a little about what is going on for you and how you are feeling.  
Statistical health information required for this referral:
What gender do you identify as? *
Your age *
Which ethnic group do you belong to? *
Obligatorisk
Our Privacy Statement:  All Little Shadow staff are bound by our agency confidentiality policy and all Counsellors must adhere to the New Zealand Association of Counsellors (NZAC) Code of Ethics and complaints process to ensure members provide a safe and ethical service.  This means that we treat all communication and information as confidential and privileged unless you consent to particular information being disclosed.  In submitting this form you agree to your details being used to make a referral to a Little Shadow Practitioner Partner.  Your personal data will be held securely and will not be distributed to any other third party.   You have a right to change or access your information.  You understand that when this information is no longer required for this purpose, official Little Shadow procedures will be followed to dispose of your data in accordance with current Health and Information Laws. *
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