Introductory Questionnaire for Wellington Students

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

1. First Name:

2. Last Name:

3. Date of Birth (DD/MM/YYYY)

(dd / mm / yyyy)

4. Massey Student ID:

(numeric only)

5. Semester Address:

6. Home Address (if different from above):

7. Phone number (mobile)

Phone Number (landline)

8. Is it okay for us to leave a voicemail or text message?



9. Email address:

10. Preferred method of contact (you can choose more than one):




if other please specify: 

11. How would you best describe your gender?





12. Course of Study:
e.g. BDes (Spatial); BN; PGDip (Psychology)

13. Please tick the categories that apply to you:





a. Current year of tertiary study:

Citizenship:

14. Number of courses you are taking this semester:

15. Ethnic Group:

If Other Ethnicity, please specify:

Attending Appointments

Please indicate when you would be able to attend appointments - please choose more than one.

The counselling hours are 8.30am to 4pm.












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 counselling. Your responses are confidential to the Counselling Service.

16. What has led you to seek help from the Counselling Service at this time?

17. For counselling to be helpful for you, what changes would you see occurring in your life?

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

19. How well have you been coping recently?  For example, are you maintaining your normal day to day routine?  If not, how is this different from usual?
(e.g. sleep, attending lectures, drug & alcohol use. Eating, exercise)

20. What would someone who knows you well say is different about you now?

21. What strategies have you tried to help you cope either now or in the past?

22. What do you think might be contributing to your present difficulties/concerns?

23. Are you currently experiencing any sort of violence within your life?


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


25. What do you consider doing at particularly difficult moments?

26. Are you currently experiencing suicidal thoughts?


26a. If you have felt suicidal, when did it begin, how often do you feel like this and would you be likely to act on it?

27. How would you know that things were better?  What changes would you notice that would indicate things are better?

(e.g. changes in your thinking, how you are feeling and behaving)

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

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.

29. Name of General Practitioner (GP) and Contact Details
It is a service requirement that counsellors must obtain the name and contact details of each client's General Practitioner

30. Have you sought help for this difficulty from your GP?


31. Please use this space to provide details of any medical condition you have that you feel we should be aware of e.g. diabetes, glandular fever, chronic fatigue syndrome.

32. Are you on any medication at present?


33. Please provide the name(s) of your medication and the dose:

34. If you have received professional help for this or any other problem in the past, who has provided this (select all that apply):






34 a. If you answered yes, please provide brief details of the help you received:

including any Community Support, or Mental Health Services

35. Have you used the Student Counselling Service before?


If your answer was yes, please add any comment on your experience:

36. Do you have a preference for a particular counsellor? If so, who?

37. Who suggested you seek counselling now?

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