Introductory Questionnaire for Wellington Students 2018

Please ensure you receive a "submission received" message when you submit your form. If you have not heard from the Student Health Centre within 2 working days after submitting your form, please ring us to ensure we have received it.
About You
First name:
Last name:
Date of birth
(dd / mm / yyyy)
Massey Student ID
(numeric only)
Semester Address:
Home Address (if different from above):
Mobile phone number:
Home phone number:
Email address:
Preferred method of contact (you can choose more than one):




How would you best describe your gender?




Course of Study:
e.g. BA, BSc

The Degree you are studying for

Please tick the categories that apply to you





Current year of tertiary study:
Citizenship:
Number of papers you are taking this semester:
Ethnicity:
If Other Ethnicity, please specify:
Attending Appointments

Please indicate when you can attend appointments - please choose more than one. The counselling hours are 8.00am to 4.00pm.












Are there any particular characteristics/experience you would like your counsellor to have?

Your Current Situation
This is the most detailed section of the questionnaire. We want to understand your situation as much as possible so please complete all the questions as fully as you can. This will help both you and your counsellor prepare for the Therapeutic Consultation. Your responses are confidential to the Counselling Service.
1. What has led you to seek help from the Counselling Service at this time?

2. For counselling to be helpful for you, what changes would you see occurring in your life and how would you know that things were better?

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

4. To what extent are you able to focus on your studies given these current issues/difficulties?

5A. What strategies have you used to help you cope so far?







5B. Doing things that help you feel more in control – if you answered yes, please give examples

6. What current supports do you have?

7A. Do you use alcohol and/or other drugs to manage your feelings?


7B. are you concerned about your drug use?


8. Safety Issues

8A. Are you currently experiencing any abuse or violence in your life?


8B. At times when you feel overwhelmed do you have suicidal thoughts?


8C. Have you recently experienced suicidal thoughts?


8D. How likely is it that you would act on these thoughts?

8E. What supports are you able to draw on during these times?






9. Medical Details
We need some brief information in relation to your health. Counsellors are not medically trained. There may be occasions when we might wish to speak to your doctor on a clinical matter. This would always be with your knowledge and ideally consent.

9A. Name of Doctor

9B. Name and location of the Medical Practice

9C. Have you sought help for your issues/difficulty from your GP?


9D. Do you have any medical condition that you think we should be aware of? Please note any medications you are taking for this or for mental health issues.

10. Have you received professional help for your current issue/difficulty, or any other problem in the past? Please tick all that apply:







If other, please specify:

11. Please include in this space anything else you feel it is important for us to know.

Privacy Policy and Terms of Service:

I am aware that my response to this questionnaire will become part of my individual confidential record of contact with the Student Counselling Service. All data is collected and maintained according to the Privacy Act 1993.  Under the act students are able to apply to access or have copies of information held about them. We may share information with other health professionals such your doctor, ideally with your permission.

Email Address

Massey Contact Centre Mon - Fri 8:30am to 5:00pm 0800 MASSEY (+64 6 350 5701) TXT 5222 contact@massey.ac.nz Web chat Staff Alumni News Māori @ Massey