Self Referral Form

Your confidentiality is important to us. This information will be submitted via a secure connection and we have taken all necessary steps to ensure your information is as safe and protected as possible.

Please complete this registration form as fully and honestly as possible.

As we want everyone to be able to access our service, if you are having difficulty completing this form don't hesitate to call us on 04 386 3861 or email us at info@anxietyspecialists.co.nz.

Full Name

Gender

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Male
Female
Gender Neutral

Date of birth

Email address

Contact number

Alternate contact number

Street address

Street address 2

City

Province

Postcode

Country

I prefer contact by:

Phone
Text
Email
Voicemail

GP Details

Referral reason

Duration of Current Problem

0-6 Months
7-12 Months
More Than 12 Months

I am currently off work on long term sick leave (6 weeks or longer)

I have a history of Mental Health problems (e.g. previous service involvement)

Self Harm

I do not self-harm
I occasionally self-harm
I frequently self-harm

Suicidal Thoughts

I have no thoughts about suicide
I think about suicide sometimes
I think about suicide most of the time
I make plans for suicide

I understand that the cost of each session (50 minutes) is $250.

I understand that missing a scheduled appointment or cancelling within 48 hours per working day between the date of cancellation and the scheduled appointment will incur a late cancellation fee as follows:

For cancellations within 24 hours: 100% of the full session cost ($250)
For cancellations within 48 hours: 50% of the full session cost ($125) if the session time is not filled by another client.

Privacy

Our service is 100% confidential – we will not disclose any information to anyone without your consent.

All information you provide to us or that we record during the course of your treatment will be stored in a secure cloud-based platform. We do not keep physical records.

If you would like us to be able to provide anyone with your personal information or appointment times, please list them below.

You consent to Anxiety Specialists providing the people listed below with updates regarding treatment and acknowledge that Anxiety Specialists will not be able to provide any information to any individual whom you have not given consent for.

Name

Relationship

Name

Relationship

Name

Relationship

Please inform us if there are any changes in relationships which require an individual to be removed from or added to this list.

A treatment summary can be provided to your GP on request.