Haerenga Hauora Counselling - Intake
Arohanui for considering us to give awhi on your hauora journey.  This referral intake form will help us better understand your situation and ensure that we can offer the best support tailored to your needs. 

This form is designed to provide our Counsellor with some insight into your current hara and challenges; by understanding these, we can better determine if our counselling services align with your hauora needs and that we are within the scope of expertise that can best support you through it.

Please take a few moments to provide us with some basic information about yourself + your situation; remembering to share as little or as much as you feel comfortable with.  Your responses will be kept confidential.
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Client information -
Please fill out the details below so we can add you to our counselling list.
Full Name: *
Date of Birth: *
Contact Number: *
Email Address: *
Referring Person (If applicable)
Name:
Relationship to Client:
Contact Number:
Email Address:
Appointment Information -
Please note that our Counselling sessions run on a recurring basis.  For more information on what this means, please check out our highlights: Click Here
Type of Session Required: *
Session Delivery:  *
Frequency Preferred:
i.e. how often you want to attend sessions *
Required
Reason for Referral: 
Briefly describe the main reason for seeking counselling services *
Current Challenges:
Please briefly describe the challenges or issues you are currently facing. *
Preferred Method of Communication:
Please note whether you prefer email or a phonecall to connect when a space becomes available. *
Availability:
What days and times are generally convenient for you for counseling sessions? *Please note we cannot guarantee these
 *
Additional Information: 
Is there anything else you would like to share?
Consent:

 *
Required
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