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Pre Counselling Form
Please complete as much of this form as you can. Our Counsellor will be in contact with you within two school days once this form is submitted. This information can only be viewed by Julie, the School Counsellor. Nga mihi nui.
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Name
Your answer
Year Level at DHS
Your answer
Preferred Pronoun
Your answer
Cellphone Number
Your answer
Email Address
Your answer
What is the best way to contact you to set an appointment time?
Text
Phone
Email
Send a runner to my classroom
Tell my Teacher/Dean
Other:
Clear selection
Who suggested that you see a Counsellor?
No one (Self referral)
Friend
Family member
Teacher
Other:
Clear selection
What are the main issues or concerns that are causing you to seek counselling?
Low mood/sadness
Stress/anxiety
Family issues
Friendship issues
Bullying
Grief and Loss
Sexual Orientation
Gender Support
Self harm/Personal safety
Hauora Wellbeing Support (Sef confidence, goal setting, time management etc)
Other:
Clear selection
Indicate a number representing the severity of your issues/concerns.
Mildly upsetting
1
2
3
4
5
6
7
8
9
10
Extremely Severe (Stops me from doing the things I enjoy)
Clear selection
How do these current difficulties affect you?
Your answer
What do you hope to get out of your Counselling sessions?
Your answer
Stay well, look after yourself. Noho ora mai
I will be in contact very soon and look forward to meeting you!
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