Request for counselling services

Date of birth

Semester Address:

Home Address (if different from above):

Mobile phone number:

Home phone number:

Email address:

Preferred method of contact (you can choose more than one):

How would you best describe your gender?

Course of Study:
e.g. BA, BSc

The Degree you are studying for

Please tick the categories that apply to you

Current year of tertiary study:

Citizenship:

Number of papers you are taking this semester:

Ethnicity:

If Other Ethnicity, please specify:

Please indicate when you can attend appointments - please choose more than one. The counselling hours are 8.00am to 4.00pm.

Are you interested in the option of group counselling?
(Groups are confidential, counsellor-led, therapeutic offerings for students on things such as anxiety, academic stress, relationships, and alcohol/drug use.)

Is there anything else you would like us to know?

Privacy Policy and Terms of Service:

I am aware that my response to this questionnaire will become part of my individual confidential record of contact with the Student Counselling Service. All data is collected and maintained according to the Privacy Act 1993.  Under the act students are able to apply to access or have copies of information held about them. We may share information with other health professionals such your doctor, ideally with your permission.