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How would you describe your gender?
Is this appointment regarding an Impaired Performance or Aegrotat application?
1. What has led you to seek Counselling Service at this time?
13. In this space please include anything else you feel it is important for us to know.
14. Have you sought help for this difficulty from your GP?
15. Please use this space to provide details of any medical condition or psychological diagnosis you have that you feel we should be aware of. Please list medication you are taking.
16. If you have received professional help for this or any other problem in the past, who has provided this (select all that apply)
if other please specify:
Do you have a preference for a particular counsellor? (e.g. male, female, or a specific person). This may make arranging an appointment slightly slower but please state preferences with reasons if appropriate below.
To give us some idea of your availability please indicate when you would be able to attend appointments (please choose more than one) The counselling service hours are 8.30 am to 5 pm
Cancellations: A charge of $10.00 will apply for failure to attend a booked appointment unless you cancel the appointment at least two (2) hours beforehand. Ideally, please cancel appointments the day before to allow other students to be seen as soon as possible.
After Hours Assistance:-
Crisis Team: 0800 800 717
Lifeline: (09) 5222 999 or 0800 543 354
Chinese Lifeline: 0800 888 880
Youthline: 0800 376 633 or free txt 234
Phobic Trust (for anxiety attacks): 0800 14 ANXIETY or 0800 142694
Page authorised by Albany Regional Registrar
Last updated on Tuesday 13 June 2017
Massey Contact Centre
Mon - Fri 8:30am to 5:00pm
0800 MASSEY (+64 6 350 5701)
Māori @ Massey