Introductory Questionnaire for Albany Students

About You
Personal Details

IF YOU ARE AT RISK, PLEASE CONTACT THE FOLLOWING:

After Hours Assistance:-

Crisis Team:  0800 800 717

Lifeline: (09) 5222 999 or 0800 543 354

Youthline: 0800 376 633 or free txt 234

Anxiety New Zealand: 0800 ANXIETY or 0800 269 4389

Depression helpline:  0800 111757

Text or phone 1737 anytime for counselling assistance

First name:
Last name:
Date of birth
(dd / mm / yyyy)
Massey Student ID
(numeric only)

How would you describe your gender?




What Ethnicity are you?

Mobile phone number:
Email address:
Preferred method of contact  (you can choose more than one)




Which campus are you studying on?

Is this appointment regarding a Supportive Document you require? (e.g. assignment extension, withdrawal/ Aerotat / Impaired Performance / Studylink)?


Attending Appointments

To give us some idea of your availability please indicate when you would be able to attend appointments (please choose more than one) The counselling service hours are 8.30 am to 4.30 pm Monday to Friday.










If you have already booked an appointment, what day, time and therapist are you seeing?

Course Of Study
Current year of tertiary study
Number of papers you are taking this semester
Columbia - Suicide Severity Rating Scale

1. In the past month - have you wished you were dead or wished you could go to sleep and not wake up?


2. In the past month - have you actually had any thoughts about killing yourself?


3. If Yes, have you thought about how you might do this?


4. If Yes, have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them?


5. If Yes, have you started to work out or worked out the details of how to kill yourself?


Do you intend to carry out this plan?


6. Have you done any of the following within the past 3 months?

6a: Attempted to kill yourself even if ending your life was only part of your motivation.


6b: Started to do something to end your life but someone or something stopped you before you actually did anything.


6c: Started to do something to end your life but you stopped yourself before you actually did anything.


6d: Taken any steps towards making a suicide attempt or preparing to kill yourself

(Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc).


6e: In your entire lifetime, how many times have you done any of these things?

Risk - continued
Other types of risk

Are you currently experiencing any of the following types of risk? (Please tick all that apply)






Your Current Situation
We want to understand your situation as much as possible so that we can help you in the most effective way. Please complete all the questions as fully (but briefly) as you can. This will help both you and your counsellor prepare for the session. Your responses are confidential!

1. What has led you to seek Counselling Service at this time?

2. How long have you been experiencing your current difficulties/concerns?

3. What things have you been doing to help you cope either now or in the past (e.g. sleep, attending lectures, drug & alcohol use, eating, exercise, self-harm, gambling, internet, pornography).

4. What would you like from counselling and how would you know if it's working?

5. Is the overuse of alcohol and/or drugs a significant coping strategy for you at present?


6. Where do you get support from? (e.g. family members, friends, a partner, (pet(s), groups/clubs?)

7. Have received professional help for this or any other problem, now or in the past? Who has provided this (select all that apply)







if other please specify: 

8. Please use this space to provide details of any medical condition or psychological diagnosis you have. (Please list medication you are taking).

9. In this space please include anything else you feel it is important for us to know.

10. Do you have a preference for a particular therapist?  (e.g. male, female, or a specific person, mandarin speaking). This may delay arranging an appointment.

Thank you for contacting us, we will reply shortly. This reply will be between 8.30am & 4.30pm Monday to Friday. For after-hours assistance, please refer to the contact details above or on our home page.

Cancellations:  A charge of $10.00 will apply for failure to attend a booked appointment unless you cancel the appointment at least two (2) hours beforehand.  Ideally, please cancel appointments the day before to allow other students to be seen as soon as possible.

Email Address

Massey Contact Centre Mon - Fri 8:30am to 4:30pm 0800 MASSEY (+64 6 350 5701) TXT 5222 contact@massey.ac.nz Web chat Staff Alumni News Māori @ Massey