Kowhai Centre Appointment - Otago Polytechnic

1. CONTACT DETAILS

Date of referral

First name *

Last name *

Date of birth *

Ethnicity

Ethnicity 2

Please tell us of any special cultural considerations we should be aware of

Please tell us your occupation if you are working; if you are seeking work; if you are a student or if you are retired

Please note: We can see university students at the Kowhai Centre but not Otago Polytechnic students. If you are an OP student, please contact Student Health on 479 6082.

2. CONTACT PREFERENCES

Phone number *

Can we contact you via text?

Yes

Can we leave a message on your phone?

Yes

Email address *

Can we email you on this address?

Yes

Address and post code *

3. PERSONAL DETAILS

Next of Kin

Please give us contact information for someone we could contact in the event of an urgent situation (eg. if you became unwell while at the Kowhai Centre and we need to contact someone to come and pick you up).

First and Last Name

Relationship to you

Phone

Are you enrolled with a GP?

Name of G.P

Medical Centre

Are you on any Medication?

Yes

Type of Medication?

4. REFERRAL INFORMATION

Are you referring yourself?

If you have been referred by someone else, please give us their details below:

Name of referrer

Relationship to you, e.g. G.P

Phone

Have you had Counselling before?

Yes

Have you been to the Kowhai Centre before?

Yes

Year

Please indicate ALL of the slots that you would be able to attend

Wednesday afternoon 3.00pm - 7.00pm

Thursday morning 11.00am - 7:00pm

Friday Morning 9.00am - 3:00pm

Counsellor Preference

Please indicate if you have a particular preference for the counsellor you will be allocated.

Reason for Referral

Please briefly explain what your hopes are in coming to counselling (eg. you’d like support with low mood). Please let us know if you are currently experiencing any suicidal thoughts.

If you are experiencing suicidal thoughts and you need urgent support, please contact one of the following numbers:

Text or phone 1737 to speak with a trained counsellor

Phone Emergency Psychiatric Services on 0800 467 846