INDIVIDUALS REQUEST FOR SERVICES FORM

 

The first step for assessment or therapy with a psychologist or Doctor is generally a referral from a GP, doctor, counsellor or other health professional. You can start with a self-referral however we may ask for more info. If you want to join the peer support group only please make a note on the form. 
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You might be seen faster if you also contact a health professional and ask for a referral. If you have seen someone in the last 6 months you can usually phone them to ask for one at no cost. They can refer on our website, by fax 09 849 2375 or reception@anxiety.org.nz 
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Our clinic is closed Sunday/Monday. We are open for appointments 9.00am - 8.30pm Tues & Wed, 10am - 7pm Thurs, 8.30am - 5pm  Fri & Sat.
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Our 24/7 Helpline is 0800 ANXIETY ( 0800 269 4389)
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*Please note we are not a crisis service - if you need immediate help call 111, or visit the mentalhealth.org.nz website >

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Fields with an asterisk (*) are compulsory.

Your preferred days and times for consistent appointments*
Will another referral from you GP, Counsellor, Mental health worker be sent through?*
Your gender*
Funding for Assessment & Therapy*
Low income criteria Before-Tax / Gross Per Week Threshold Limits:
- Single 16-17 years – $531.61.
- Single 18+ years – $648.92.
- Married / civil union or de facto couple (with or without children) – $963.80.
- Sole parent 1 child – $741.41.
- Sole parent 2+ children – $781.14.
If you prefer, you can download a printable form for emailing here.
Email your completed form to: reception@anxiety.org.nz

Copyright © 2020 Anxiety New Zealand Trust

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