The ACFB Fund

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Collateral Questionnaire

Please use the survey below to help us gather information about an applicant in our psychological services program. Please fill out the questions thoroughly and with as much detail as possible. This helps inform treatment planning.

Ideally, this form should be filled out by someone close to the applicant who has known them since before age 12 but preferably before age 3. Thank you for assisting with this service on behalf of the applicant!

If the applicant you are answering about has not yet reached the age for the teen or adult questions you can just leave them blank or put “Not Applicable” in the answers for those questions.

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Who are you completing this questionnaire for?
Your Name
Were there any complications either during the pregnancy or birth? Were they born early, on-time, or late? Any medical issues? What was the delivery like?
Was there any significant trauma? Were they a happy or fussy baby? Any medical issues? Did they meet their developmental milestones? If not, what happened? Give us a good overall picture of the applicant during their infant years.
Was there any significant trauma? Were they a a difficult toddler? Any medical issues? Did they meet their developmental milestones? If not, what happened? Give us a good overall picture of the applicant during these years.
Was there any significant trauma? Were they a a difficult child? Any medical issues?Did they get along well with others? Did they meet their developmental milestones? If not, what happened? Did they go to school on time? What was school like for them?

Give us a good overall picture of the applicant during these years.
Was there any significant trauma? Were they a a difficult teen? Any medical issues? Did they meet their developmental milestones? If not, what happened? What was school like for them? Did they get in trouble at school? How were they in relationships both within and external to family?

Give us a good overall picture of the applicant during these years.
Was there any significant trauma? Medical issues? Any behaviours of note?

Give us a good overall picture of the applicant during these years.
By checking "Yes I confirm" below and submitting this survey I am confirming I am the person listed above and any information provided, to my knowledge, is accurate.

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About Us

A Change For Better (ACFB) is a web-based platform for members of the public and mental health professionals alike. ACFB is a safe place to learn, interact, and gain support. 

Recognizing that significant change can take time, ACFB provides members with tools and support to achieve sustainable change in their lives.

The ACFB Fund was born out of the idea that with power of community, we can create a self-sustainable means for those who need mental health support and psychological assessments. Funded by ACFB and private donations and assessment fees, the ACFB Fund hopes to grow to help as many Kiwis as possible.

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Charity Details

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A Change For Better – The ACFB Fund is a registered charity with Charities Services NZ

Charity Number: CC61221

If you are looking for autism related funding through NASC/ Whaikaha then this is not the assessment for you at this time.

Whaikaha have changed their minds after years of accepting telehealth diagnoses and have said our diagnoses no longer meet their long list of strict criteria. We will be providing support to those who already received a diagnosis with us but are not sure about going forward if we will continue the higher requirements now set forth by Whaikaha. 

In the meantime, we are advocating to anyone and everyone who might be able to help us and would love your support as well. Please make a complaint. You can find more information on the Whaikaha website here.

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The ACFB Fund is not a crisis counselling centre, and we cannot provide emergency services for active or prospective clients.

If you’re in a life-threatening situation or experiencing a mental health emergency, this service is not appropriate for you at this time. Instead, use the following helplines to get the support you need:

  • Lifeline New Zealand: 0800 543 354 (call or text)
  • Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO)
  • 1737 – Need to Talk?: Free call or text 1737 to speak with a trained counsellor (available 24/7)
  • Healthline: 0800 611 116 (available 24/7)

These contacts are available for immediate crisis support and can help connect you to further assistance.

Confirm

Thank You

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Thank you for submitting your application to The ACFB Fund.

Our team will review your application and be in touch with you soon.

To access some of our free resources then please take a look at our Wellness Info