Napier Family Centre

Sexual Violence

Our Counselling Service has a contract with ACC called Integrated Services for Sensitive Claims that allows people who are survivors of sexual violence (being a physical and/or mental injury suffered as a result of sexual abuse or sexual assault), receive funded counselling support.

For more information and help to access ACC-funded support visit the ACC’s website here.

If you feel like you need help please fill out our contact form below, and a member of our staff will be in contact with you as soon as possible.

Your details
Name*
First Last
Address*
Street Name and Number Suburb Town Region Postal Code
Phone*
Email
Sex*
Date of Birth:*
Ethnicity*
- NZ European/Pakeha
- Māori
- Pacific Island
- Asian
- Indian
- Other
Is this enquiry for counselling for you or someone else?*
- It's for me
- It's for me AND someone else
- It's for someone else (e.g a child/relative/friend)
Tell us what the counselling is for?*
- Emotional management
- Relationship counselling
- Depression/anxiety
- Post-natal depression/anxiety
- Sexual abuse
- Something else
- Perinatal distress/trauma
Type of Counselling:*
- Individual counselling
- Relationship counselling
- Family counselling
- Child or young person counselling
Counsellor Preference*
- Male
- Female
- No Preference
Preferred Session type*
- Face to Face
- Zoom / Telephone
- No Preference
Child/Children's Details
Child/Children's details
Click the + symbol to add a new row and enter more children's details.
First name Last name DOB
What is your relationship to the child/children?
Child/children's current address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Caregiver(s) details:
Who are the child's main caregivers? Use the + symbol to add a caregiver.
First name Last name Relationship to the child
Reason for Referral
In a few words tell us about your/the client's issues (you will be able to describe in more detail later when we talk with you).*
What Days and times are best suited to you? We DO NOT offer weekends or after 3.30pm however we will endeavour to work in with your needs. We cannot guarantee we have availability on your specified days and times. (CHB is currently only on Wednesdays).
Is there anything else you would like to tell us?
Funding Details:
Is the counselling requested self-funded?
- Yes, I will pay the fees
- No, I will need financial assistance to pay the fees
- I have funding arranged by another organisation
- I don't know
Agency:
Agency Name Contact Person Phone Email
Are there other agencies involved?
If there are other agencies or organisations involved regarding this person/people please tell us who they are.
Additional Agency information e.g. referral letter etc (if any)
Max. file size: 100 MB.
Please include any additional referral documents for your client
Agency/Organisation(s) details:
Use the + symbol to add another agency or organisation.
Agency name Contact person Phone or email
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First name	Last name	DOB

First name	Last name	Relationship to the child

Agency name	Contact person	Phone or email

Sexual Violence

Sexual Violence

Your details

Child/Children's Details

Reason for Referral

Funding Details:

Are there other agencies involved?

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