Phone: 343-3391 Fax: 343-2934

29 Yaldhurst Road, Sockburn, Christchurch

PO Box 6088, Upper Riccarton, Christchurch 8442

Online Referral

New Client Referral Form

Please complete this referral form for a Petersgate counsellor to contact you.

NB: Please use this form only if you're making a request for an initial counselling session at Petersgate Counselling Centre for yourself, a patient or a client. This form should not be used by existing clients.

The information you provide will remain strictly confidential to Petersgate Counselling Centre.


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Please note that certain email apps mistakenly divert messages from new contacts or with certain words into the app's Spam/Junk folder. Please check this folder in your email app if you indicate email contact as your preferred method of contact and don't hear from us within a few days.


Purpose

Please use this space to state what is prompting you/your client, patient or employee to seek counselling, and whether a particular counselling approach is preferable. This information helps us to ensure the best possible client-counsellor fit.

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Counselling fees will be paid for by...

Please identify who will be paying for the counselling sessions. If you select Other in the drop-down menu then please identify this person's relationship to you in the next section.

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Your relationship to the person who will be paying for your counselling.

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Availability

Please let us know the days and hours you could be available to attend counselling at Petersgate. The more options you provide, the quicker we'll be able to find an available counsellor. Please note that appointment times Monday to Thursday are from 9am to 7.30pm and Friday from 9am to 4.00pm.

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Additional Information

Please feel free to provide additional information here. For example, this might be about your availability to attend counselling or a request to see a particular counsellor.

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Request Made By

Please tell us who is submitting this request. If you select Other in the drop-down menu then please explain your relationship to the person for whom the request is being made.

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Your contact details if this isn't a self-referral

Please provide your first and last name, the name of your organisation, and your contact details, if you're submitting this request for counselling on behalf of someone else.

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Authorisation

I confirm that I am submitting this request for counselling for myself, or that I am authorised to submit it on behalf of the person named above and am doing this with their knowledge and consent.

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