Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

We would only contact this person in an emergency where your immediate health or safety is concerned, we would attempt to inform you first before making contact with them.

First Name

Last Name

Emergency contact phone *

(###)

###

####

Terms & Conditions *

I have read and accept the terms and conditions of Atawhai Counselling & Supervision https://www.atawhaicounselling.com/terms-conditions

Yes

Acknowledgement *

I understand and acknowledge that the therapeutic support and advice given by Atawhai Counselling & Supervision is not intended as medical advice and that Atawhai Counselling & Supervision are not medical or diagnostic practitioners.

Yes

PractiSpace *

I understand and acknowledge that Atawhai Counselling & Supervision is not liable for loss of property, injury or loss of life resulting from attending appointments at PractiSpace (1 Gibraltar Ave, Parnell, Auckland 1052).

Yes

Zoom appointments only N/A

Crisis support & intervention *

I understand & acknowledge that Atawhai Counselling & Supervision are not a crisis support & intervention service and that they may, at their discretion refer me to crisis support services as set out in their terms and conditions.

Yes

Confirm *

I confirm the information above is accurate at the time of filling in this form. I understand that Atawhai Counselling & Supervision may use this information in an emergency where my immediate health and safety is concerned.

Yes