Counselling Application – Test

Counselling Application - Test

Please enable JavaScript in your browser to complete this form.

Name

Please provide the name of the individual who needs counselling services

Name of Guardian or Support (if applicable)

Minors and adults who choose to are entitled to add a Guardian or Support Person to their application.

Gender

Male
Female
Non Binary
Other

Please let us know the gender of the individual who needs counselling services

Date of Birth

Phone

Yearly Income

If this application is for a child (younger than 18) who is still living at home then please make this the household income.

For adult couples (18 or older) this is your household regular income from any source - salary, wages, WINZ, student allowance etc

For any other single adult (18 or older) this is your regular income from any source - salary, wages, WINZ, student allowance etc

How did you hear about The ACFB Fund?

How many sessions are you looking for?

Please note that we cannot guarantee that we can provide this number of sessions but it helps us determine what you might use in a 6-month timeframe.

Have you applied for The ACFB Fund before?

Would you be happy to see an intern online?

Yes
No
Unsure but willing to try it out

Please note that interns have lower caseloads, higher amounts of supervision, and is the same quality as other professionals. By selecting this option, you are helping to train the next generation of Counsellors. If you choose this option, we will ask for a koha of $50 per session which will help cover their additional oversight and training and go into supporting programs like this to continue for years to come.

Why are you seeking support?

Have you received counselling before? If so, tell us what was helpful/not helpful.

Have you experienced trauma? Tell us more.

1 month's worth of bank statements or a letter from your ACFB Fund vetted professional

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

Driver's License/ Passport or other means of identity

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

You can do this as up to 2 images if you need.

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

Copy of any referral forms you might have from other health providers

Click or drag files to this area to upload. You can upload up to 3 files.

You can do this as up to 3 images if you need.
File Types accepted: jpg,gif,pdf,heic,png,webp,jpeg

In submitting this application I understand/agree with the following :

* That my information and application will be viewed within the ACFB Fund Clinical Team to determine my eligibility.
* I have provided documentation of ALL income sources and understand that if I am dishonest about my true income, I may not be accepted into the program.
* In submitting this application I understand and agree to all the terms and conditions of this program, including the no-refund policy should I make a payment.
* I understand that this is NOT a medication management service. If the results of any assessment include a recommendation for medication then ACFB will refer to the Nelson Clinic (who will accept any diagnosis provided by ACFB). There will be a cost for any services then provided by the Nelson Clinic - they can advise on what those costs will be.
* I also understand that The ACFB Fund will keep confidential records on the statistics around how my application/funding is used and may reach out for this purpose.

If you are unsure about any of these, please email info@acfbfund.org.nz with your questions before submitting this application

Thanks to our Sponsors!

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.

Quick Links

Charity Details

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.

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.