Refer your client for counselling

This form is designed for Health Professionals, GP's, Community-based agencies that wish to refer a person to Wingspan.


Due to high demand we do have a waiting list of 2-8 weeks.


This Request-an-appointment form takes an approximately 5 mins to complete. 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. Important: You must log in from the same computer for the save function to work.

Client Details

Date of Birth*
Do you feel concerned for the safety of the client, or their family/friends?*


Wingspan Counselling is not a crisis center and our office opening hours vary. If anyone is in immediate danger call 111 and ask for Police. They will arrange protection and support.

If you’re in danger but it’s not safe for you to speak: Stay silent, call 111 then push 55. You will be put through to Police automatically. Listen carefully to the questions and instructions from the call taker so they can assess your call and arrange assistance for you.

For Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO).

For Youthline: 0800 376 633, Text 234 or email


Please detail if known.
State "None" if no medication have been prescribed in the past 6-months, or "Unknown" if you do not know.
Please provide as much information as you can (i.e. Agency Names(s), Phone Number(s) & Key Contacts).
Current Issues / Concerns *
Other people living in the client's home [names, ages, gender, relationship].

I hereby confirm that the client has provided me with their permission to conduct Wingspan Consulting on their behalf and consented to provide this personal information to Wingspan Trust with the intent of establishing a counselling appointment for the client.

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