Booking Form

Life Linc Counselling has been offering affordable counselling to all those who seek it in Nelson-Tasman since 1974. We are able to keep the costs to a minimum because our counsellors donate their time, and the client contributions helps to cover administrative costs and expenses. We receive no Government funding and rely solely on grants, sponsors and donations from our service users.

If you are needing to make an Agency Referral, please fill out our Agency Referral Form HERE.

Talk to us...

Life Linc Counselling is available in Nelson, Richmond and Motueka.
Access up to 10 sessions for individuals or relationships (couples). Contact our counselling coordinator to find out more details or fill out the referral form below to start the process.

Referral Form 2024

Client Referral Form

What kind of counselling are you seeking? *

Individual

Couples

Client 1 Name: *

Client 1 Name:

First

Last

Address *

Contact Number *

Is it ok to leave a voice mail message or text at this number *

Yes

Date of Birth (We are unable to assist anyone under age 16 currently.) *

Country of Birth *

Ethnicity *

NZ Maori

NZ Pakeha

Pasifika

Asian

European

North American

South/Latin American

Middle Eastern

African

Other

Gender *

Male

Female

OtherOther

Occupation

If you have children, can you please list how many children you have and their ages.

Email *

Your emergency contact or GP practice:

Any medications, diagnoses, mobility, or health issues we need to be aware of?

Have you had previous counselling with Life Linc?

Are you engaging with any other support services?

Counselling fees will be paid for by...

Client 2 Name: *

Client 2 Name:

First

Last

Address

Client 2 Contact Number *

Date of Birth *

Client 2 Email *

Client 2's Gender *

Male

Female

OtherOther

Client 2's Ethnicity *

NZ Maori

NZ Pakeha

Pasifika

Asian

European

North American

South/Latin American

Middle Eastern

African

Other

Occupation

If you have children, can you please list how many children you have and their ages.

Your emergency contact or GP practice:

Any medications, diagnoses, mobility, or health issues we need to be aware of?

Have you had previous counselling with Life Linc?

Are you engaging with any other support services?

Collaborative reason for counselling? *

Collaborative availability? *

Reason for Referral

Reason for Seeking Counselling

Availability

Monday

Tuesday

Wednesday

Thursday

Friday

Please let us know the days you could be available to attend counselling at Life Linc. The more options you provide, the quicker we'll be able to find an available counsellor.

Request Made By

I confirm that I am submitting this request for counselling for myself, or that I am authorised to submit it on behalf of the person named above and am doing this with their knowledge and consent.

Yes

If you are human, leave this field blank.

Agency Referral

If you are from an agency, GPs, or other referring person, please use our Agency Referral Form, which can be found HERE.

Community Contribution Model

The cost per counselling session is based on your income and is a sliding scale. Fees start from $30 per session for individual counselling and $60 per session for couples. You can view all the rates here.

The true cost of counselling is approximately $90+ per session. Through grants, donations and community support, Life Linc is able to subsidise this cost. We ask clients to contribute a minimum of $30 per session where possible. If financial circumstances make this difficult, we encourage clients to discuss alternative contribution arrangements with us. No one will be turned away solely because of an inability to pay.

Payment

The counselling session cost is expected to be paid on the day of each session. Our bank details are Life Linc Charitable Trust, NBS Bank, 03-1354-0669814-00. If you are having trouble making the payments for your counselling, please contact the office at 03 548 2400 to discuss options.

Appointment Times

You will set a weekly appointment time with your counsellor. We have counselling available Monday-Friday from 9am to 5pm.