Need to talk?

Counselling Your Way is currently only available in Auckland. To check what is available in your area please contact your local centre.

Counselling Your Way

Is this a referral?(Required)

No, this is for myself

Yes I’m referring my friend or whānau member

Yes, this is a service referral

Referrer Name(Required)

First Name Last Name

If you are referring a friend or whānau member, please put YOUR name in these fields.

Name of organisation

Type of organisation

Reason for referral

Name(Required)

First Last

Details of person to receive counselling(Required)

First Name Last Name

If you are referring a young person, friend or whānau member, please use THEIR name in these fields.

Preferred Name

Pronouns

Date of Birth(Required)

Email Address(Required)

Email Address Confirm Email Address

This field is hidden when viewing the form

Phone

Phone(Required)

Preferred Method of Contact

Address(Required)

Street Address Address Line 2 City

How did you hear about us?(Required)

Comments

This field is for validation purposes and should be left unchanged.