Wingspan | Request an appointment for self referral

This form is for self-referrals. If you are wanting to request a counselling appointment for yourself or a loved one – you’ve come to the right place.

If you are a Healthcare Professional wanting to make a referral for your client, please submit a Referral Form. Go to the Healthcare Professionals page for more information.

This Request-an-appointment form takes an approximately 10 mins to complete, so get comfortable. The good news is that there is an option to save and return later.

If you select the ‘Save Your Progress’ button you will be presented a security code on screen that you will need to re-enter when you want to continue with completing the form.

Your Details

First Name*

Last Name*

Street Address*

Suburb*

City*

Post Code*

Country*

Email*

Mobile/Phone*

Other contact number

Is it OK to say who we are when leaving a message?*

Yes

Date of Birth*

Date

Year

Country of Birth*

Name the practice, doctor, school or community social service who referred you to Wingspan?*

Please enter 'None' if you were not referred.

Voluntary Contribution Guidelines*

Wingspan Trust is a charitable organisation that relies on funding, donations, and voluntary contributions to provide professional counselling services to Tāmaki Makaurau.

In order for everyone to receive counselling, we offer a range of price options to cater to all financial situations. Please note, all voluntary contributions are negotiable.

Not sure what to pay? Check our suggested contribution rates according to income below:

Please note these are suggestions only, your financial means may vary.

Household income	Individual session	Couple session	Family session
$10,000 - $20,000 per year ($190 - $385 per week)	$40	$45	$50
$30,000 - $40,000 per year ($575 - $770 per week)	$80	$85	$90
$50,000 - $60,000 per year ($960 - $1,150 per week)	$120	$125	$130
More than $60,000 per year ($1,150+ per week)	$140	$160	$180

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Request a counselling appointment

Your Details

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