If you have any acute or urgent mental health concerns, please contact 911 CONTACT USTo contact us, please select one of the options below We are currently not accepting any new Private or Sensitive Claims therapy referrals Contact Form * Brief Intervention Therapy ADHD Assessment Request General Enquiry PRIVATE PAY Due to increased demand for our services, from 1 November 2021, we will NOT be accepting private pay referrals. Brief Intervention therapy is still being offered. FeesPrivate Consultation Fees are charged at an hourly rate and are dependent on the profession of the therapist. Psychologist $120 - $160 Psychotherapist $100 - $140 Counsellor / Arts Therapist $80 - $130 Brief Intervention Therapy (cognitive behavioural therapist) $100 Rates are GST exclusive Psychiatry Due to increased demand for our services, we are currently not accepting private psychiatry referrals. Client DetailsReferral Type Referral * Who are you filling out this form for? Myself Someone Else (with their consent) Name * Client's First Name Client's First Name Client's Last Name Client's Last Name ACC Claim Number Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 We are currently unable to assess children and adolescents for ADD/ADHD. If you are under 18, we suggest that you either contact a Paediatrician directly Dr Garth Smith | Paediatrician or contact your GP to request a referral to CAMHS for a face-to-face assessment. NHI Number Phone * Email * Location * Comment * General Enquiry Attention Message * Brief Intervention Therapy This service is offered by Mark Alison (CBT Therapist) It can be useful for the following: Problem Solving Anxiety (mild) Depression (mild) Relaxation Work Stress Supporting Parents/Caregivers Smoking Cessation Covid-19 Stress Unhealthy Coping Habits For more information on Brief Intervention Therapy, please click here. BI Therapy * Do you think Brief Intervention Therapy would be suitable for you and are interested in this approach Yes No Clinical PreferencesPlease select your preferences for consideration from the following options telehealth * Yes No Are you willing and able to meet using Telehealth consultations Preferred Gender * Clinician's Gender No Preference Male Female Preferred Profession * Profession First Available Therapist Psychologist Psychotherapist Counsellor Arts Therapist Social Worker Modalities Therapy Type/Focus No Preference ACT (acceptance and commitment therapy) Art Therapy CBT (cognitive behaviour therapy) DBT (dialectical behaviour therapy) Eating Disorders EMDR (eye movement desensitisation and reprocessing) Family Therapy Hakomi ISTDP (intensive short-term dynamic psychotherapy) LBGTQ+ Mindfulness Narrative NLP (neuro-linguistic programming) Play Therapy Psychodynamics Relationship Solution-Focused Therapy Somatic Systemic Trauma Yoga Other Triage Questions Q1 DHB MH Involvement * Have you (client) had any recent involvement with a DHB mental health team Yes No DHB Involvement * Q2 Historical MH Treatment * Have you (client) previously received any mental health treatment Yes No MH Treatment * Q3 Psychiatric Medication * Have you (client) been prescribed any psychiatric medication Yes No Medication * Comments * Referrer Details Referrer Name * Referral Source * Referrer Email * Referrer Phone * Referral Documents Files must be less than 2 MB.Allowed file types: pdf doc docx. CAPTCHAWe'd like to prevent automated spam submissions. Please demonstrate that your are not a robot. Blenheim Therapy Rooms Address: 4 Purkiss Street Springlands, Blenheim, New Zealand 7201
