Counselling Request Form - Read Me

Please complete the form below to request a counselling appointment with Shiloh counselling. 

Only Shiloh counselling will have access to this information. Your responses will be kept private and secure. The information will not be used for a discriminatory purpose. You can change this information in the future by emailing help@shiloh.org.nz

Please note: Due to Covid-19 all Shiloh counselling sessions will be online or by phone. We are unable to offer in person appointments. 

Shiloh Counselling is not a crisis service. if you are looking for immediate crisis support, please refer to the Counties Manukau Mental Health page.

Counselling Request Form

Personal Details

Which country were your born?
Which ethnic group best describes you?
How did you hear about Shiloh Counselling?

Availability

Counselling sessions are usually for 60 minutes

Issues & Goals

What are the main issues that you want to discuss with the counsellor?
What are your goals for counselling?

Voluntary Contributions

What best describes your current situation?
Our focus at Shiloh Counselling is being able to provide counselling for those that finance presents a barrier to accessing professional counselling. Therefore we need to be able to prioritise those with the greatest need. Answering the following questions and making a voluntary contribution if you are in a position to do so helps us to continue to do this.