Introductory Questionnaire for Albany Students

About You
Personal Details
First name:
Last name:
Date of birth
(dd / mm / yyyy)
Massey Student ID
(numeric only)

How would you describe your gender?




Mobile phone number:
Email address:
Preferred method of contact  (you can choose more than one)




Is this appointment regarding an Impaired Performance or Aegrotat application?


Have you already booked an appointment to see a Counsellor?

If yes, what date is your appointment?
Course Of Study:


If you are a distance student, would you prefer a Skype Therapy session?

Current year of tertiary study
Number of papers you are taking this semester
Your Current Situation
We want to understand your situation as much as possible so that we can help you in the most effective way. Please complete all the questions as fully (but briefly) as you can. This will help both you and your counsellor prepare for the session. Your responses are confidential!

1. What has led you to seek Counselling Service at this time?

2. How long have you been experiencing your current difficulties/concerns?
3. How well have you been coping recently? (e.g. sleep, attending lectures, drug & alcohol use, eating, exercise).
4. What are your thoughts about what might be contributing to your present difficulties/concerns?  (e.g. what might be keeping the problem going?)
5. What would someone who knows you well say is different about you now? (if anything)
6. What strategies have you tried to help you cope either now or in the past?
7. For counselling to be helpful for you, what changes would you see occurring in your life?
8. Is the overuse of alcohol and/or drugs a significant coping strategy for you at present?
9. What do you consider doing at particularly bad moments?
10. Are you currently experiencing suicidal thoughts?

10a. If yes, how often do you feel like this and would you be likely to act on it?
11. Where do you get support from? (e.g. family members, friends, a partner, (pet(s), groups/clubs?)
12. How would you know that things were better?  What changes would you notice about your thinking, and how you are feeling and behaving that would indicate things are better?

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.

Attending Appointments
We are nearly finished - we don't need much more info now.

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










Thank you for contacting us, we will reply shortly. This reply will be between 8.30am & 5pm Monday to Friday. For after-hours assistance, please refer to the contact details below or on our home page.

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

Email Address

Massey Contact Centre Mon - Fri 8:30am to 5:00pm 0800 MASSEY (+64 6 350 5701) TXT 5222 contact@massey.ac.nz Web chat Staff Alumni News Māori @ Massey