Donate now

Trauma counselling self-referral form

Home Trauma counselling self-referral form

You can fill in this form on your own, or a support person can help you.   

Refugee Trauma Recovery is not a crisis service. If you are in immediate danger please call 111.  We offer counselling to people from a refugee background who suffer from psychological symptoms from having experienced or witnessed torture or traumatic events before to coming to New Zealand. 

Please complete this form with as much information as possible. Fields marked with * are required. 

Read our Privacy Statement

Who is completing this form

Are you filling out this form for yourself?
Are you a support person (friend, parent, or other family member) completing this form for someone?
Does the person know you are filling out this form for them?

Details of the support person:

Client details

Would you like an interpreter?

Mental health

Have you already been to counselling or talked to someone?
Please describe how you are feeling or what you are experiencing (select all that apply)