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Counselling Booking Form

Welcome Bay Community Centre provides short-term, general counselling services for the community. While we are not a crisis service, we support individuals in fostering personal growth and developing healthy coping strategies.

Counselling Bookings Form

First Name

Last Name

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

DOB

Gender

Is this counselling for:

Someone aged 16-20

Or an adult over 21?

Parent or Guardian details

Have you used any Welcome Bay Community Centre services or programmes before?

Yes

No

Please select

Counselling

Cooking

Food

Peer Support

Clothing Day

Women’s Groups

Parenting

Other

Please state

Do you have any diagnosis that is relevant to counselling?

No Diagnosed Conditions

ADHD

PTSD

Bipolar

BPD

Autism

Depression

Anxiety

Eating Related

Other

Please state

Do you need help with anything else?

Yes

No

Please state

Do you use any other services in Tauranga for support?

If anyone else in your whanau currently seeing a counsellor at Welcome Bay Community Centre that you know of?

When are you available for counselling?

Monday

Tuesday

Wednesday

Thursday

Our appointments are between 9am and 3pm on weekdays only.

Reason for counselling:

Grief/Loss

Separation/Divorce

Parenting

Anxiety

Depression

Relationship

Work Stress

Personal Stress

Significant Life Changes

Other

Please state

Referral

Self Referral

Outside Agency Referral

Organisation Name

Name of the Referrer

Email

Phone

Can you tell us a bit about what you would like counselling for (so we can fit you with the right counsellor)?

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