Contact & Referral Form

Please fill in the following referral form and we will get back to you as soon as we can.

Click here to view our phone, email and address details.

"*" indicates required fields

Name

First Last

Email Address

Contact Phone Number*

Address

Street Address City

Date of Birth*

How many children under the age of 18 do you have?*

What do you need help with?*

Family violence services available*

General counselling services available*

In your own words describe the current problems or issues you wish to address, and how they are impacting on you or others currently.

What day or time would suit you best for appointments?

If you are completing this referral on behalf on someone else, please include your name, contact details and relationship or organisation.

This field is for validation purposes and should be left unchanged.

Office Hours

Masterton Office Hours are from Monday to Thursday. 8.30am to 5.00pm

Featherston Office Hours are on Friday 8.30am to 5.00pm

Counselling Services
06 377 5716
Family Violence Services
06 377 0933

Please click the link to find out about our counselling fees. ChangeAbility Fees

If you want to make some changes in your life, you can talk to us.
It’s confidential. And it might be the best thing you’ll ever do.