ACFB General Application Form – 2024

ACFB Clinical and Other Psychological Services Application Form

Please enable JavaScript in your browser to complete this form.

Name of Applicant *

First

Last

Email *

Phone Number *

Date of Birth

Gender *

Male
Female
Non-Binary
Other

If other, and wish to explain:

You can advise how you would like your gender to be defined here.

Parent, Guardian, or Support Worker Name

First

Last

Location *

Northland
Auckland
Waikato
Bay of Plenty
Gisborne
Hawke's Bay
Taranaki
Manawatu-Whanganui
Wellington
Tasman
Nelson
Marlborough
Canterbury
West Coast
Otago
Southland

Ethnicity *

NZ European
Maori
Pasifika
European
Asian
North American
South American
African
Other

How did you hear about us? *

Which pathway would you like to take?

Sliding scale - will require income testing
WINZ - will require a WINZ verfication letter dated within 30 days of application
Student ID - tertiary students with a valid ID
Standard - no income testing

1 month's worth of bank statements, a WINZ letter or an IRD Summary of Earnings

Click or drag files to this area to upload. You can upload up to 5 files.

You can do this as up to 5 images if you need. Please make sure it is your most recent statement. We are using this to validate your regular income.

File Types accepted: jpg,gif,pdf,heic,png,webp,jpeg

Please provide a copy of your identification

Click or drag files to this area to upload. You can upload up to 2 files.

This can be a drivers license, passport, or any other document that clearly shows your face, name and date of birth.You can do this as up to 2 images if you need.

File Types accepted: jpg,gif,pdf,heic,png,webp,jpeg

Have you ever experienced the following (Select all that apply) *

None apply
ADHD
Autism
Bipolar disorder or manic episodes
Depression - short term
Depression - long term
Chronic medical problems
OCD
Domestic violence
Seizures
Iron deficiency (current)
Anxiety - short term
Anxiety - long term
Self harm
Attempted suicide
Homelessness
Neurodevelopmental disorder
Personality disorder
Psychosis
Traumatic brain injury or other head injuries
Addictions
Medical trauma

Are you currently in crisis or experiencing thoughts of suicide with the intent to harm yourself?

What support are you looking for?

Other Psychological Services
Counselling, Occupational Therapy (OT) or Whanau Support
Group Therapy

Which professional are you looking to seek support from?

Denise Van der Vlis - Counsellor
Donelle Dewar - Occupational Therapist
Sarah Harrison - Psychologist
Kiia Naidoo - Educational Psychologist
Kate Nitschke - Educational Psychologist
Dr. Natalie Peart - Clinical Psychologist
Dr. Amy Marschall - Clinical Psychologist

Check out the details for these team members at this link if you want to know more before making a choice - ACFB Clinical Team

Choose one of Denise's services below:

Counselling
Whanau Support

Counselling is better suited to the individual needing support versus Whanau Support which is tailored help for those in someone's life with challenging mental health or behavioural needs. Whanau Support for this professional is limited to 6 sessions.

Choose one of Donelle's services below:

Occupational Therapy
Whanau Support

Choose one of Sarah's services below:

Whanau Support
Psychological Support - non-diagnostic

Psychological Support is better suited to the individual needing support versus Whanau Support which is tailored help for those in someone's life with challenging mental health or behavioural needs. Whanau Support for this professional is limited to 3 sessions.

Choose one of Kiia's services below:

Whanau Support
Psychological Support - non-diagnostic

Choose one of Kate's services below:

Whanau Support
Psychological Support - non-diagnostic

kind you process

Choose one of Natalie's services below:

Psychological Support - non-diagnostic clinical consult

Choose one of Amy's services below:

Psychological Support - non-diagnostic clinical consult

Please tell us below what kind of group support you are looking for.

This service currently has a wait list. As we create our next set of groups, we will adapt them to those on this waitlist to ensure most relevant content to those interested. There is no commitment to need to continue should the groups offered later not suit your time or needs. Please also put in the box above any days/times that work better for you ongoing. This will help us best plan our timing for these groups.

What service are you seeking?

Functional Assessment (FA)
Treatment Planning (TP)
Combination - FA & TP
Workplace Accommodation Report (WAR)
Educational Accommodation Report (EAR)
Full Service - includes FA, TP, & choice of EAR or WAR

Are you in the process or have you completed your ADHD or autism assessment with The ACFB Fund?

Yes, have completed and received my diagnosis
Yes, in the process and have seen the psychologist
Yes, in the process but haven't seen the psychologist yet
No, I do not have a diagnosis
No, but I've been diagnosed elsewhere
I am applying along with this application

From the answer to the question above, it appears you would qualify for Pre-diagnosis pricing. Do you understand and wish to continue?

From the answer to the question above, it appears you would qualify for Post-diagnosis pricing. Do you understand and wish to continue?

Those without a diagnosis are charged post-diagnosis pricing because there will be more clinical work needed for this service.

Any psych or school reports, letters, or anything additional you want to upload, please do so below:

Click or drag files to this area to upload. You can upload up to 5 files.

Max of 5 uploads

ACFB Clinical and Other Psychological Services Application Form

Thanks to our Sponsors!

About Us

Quick Links

Charity Details

Thank You