Counselling - Appointment Request Form

If you are in need of immediate assistance, please call 000 or the Mental Health Line (24 hrs) on 1800 011 511.

Thank you for contacting the University of Newcastle Counselling and Psychological Services (CAPS).

Once you have sumbitted this form, we will contact you to discuss your issue via phone or your University email. Our standard response time is within 48hrs - this may be impacted by service closures and periods of high service demand.

If you need assistance to complete this form, please contact us by phone (02 4921 6622) or email (counselling@newcastle.edu.au) from Monday to Friday, between 9:00am and 5:00pm.

We value your privacy, and we have a strong commitment to confidentiality. The information you provide on this form will be kept within Counselling. However, if you disclose that you can have current plans to harm yourself or others, and we are unable to contact you, we may need to contact the person you list as an emergency contact or emergency services. The information you provide will assist us to provide a personalised response to address your needs.

We do not monitor this form after 3pm Monday to Friday, or on weekends or public holidays.

If you require support outside of business hours, contact the

University After Hours Support Line

Ph: 1300 653 007 / SMS: 0488 884 165.

First Name *

Last Name *

Preferred name (optional)

Student number *

Are you currently located overseas? (i.e. outside of Australia) *

YesNo

Thank you for reaching out to Counselling. We are sorry to hear you have been experiencing a difficult time recently.

We note that you are currently located outside of Australia. Under Australian health regulatory law, our counsellors are unable to provide advice to, or undertake consultations with, students located outside Australia. We can, however, offer the following suggestions for accessing support:

We have a range of self-help resources to improve study and wellbeing, that are accessible right now to all students. You will also find a range of online programs designed to provide you with skills and strategies to maintain your wellbeing whilst engaging in study.

The University of Newcastle is collaborating with TalkCampus, a global, peer-to-peer service, that offers students a safe and engaging platform to support mental health and wellbeing, in a range of languages. Simply download the free app from Google Play or the App Store

For any program or academic progress concerns, please forward your queries to ASKUON. They can also help you to direct any enquiry to the right service, including fees and student advice.

For emergency and mental health support within your current country of residence:

Befrienders connects you to help in your country and provides mental health information

Suicide Stop is a user-friendly haven where people from all over the world can come to easily find relevant suicide or self-harm hotlines, emergency numbers, crisis lines, wellbeing and mental health online chats, and resources for online therapy

Please contact us at counselling@newcastle.edu.au if you have any further questions, and please don’t hesitate to contact us on your return to Australia.

Residential address - street name, suburb, postcode *

Phone Number: *

University Email Address *

DOB *

Gender

MaleFemaleI use another term

Gender identity:

Pronouns (e.g. she/her, he/him, they/them etc)

Do you identify as Aboriginal or Torres Strait Islander *

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNeither Aboriginal or Torres Strait Islander

Emergency Contact Details

Name *

Relationship to you *

Phone Number *

This person may be contacted if we have serious concerns about your wellbeing and are unable to reach you.

Enrolment Information

Are you a domestic or international student? *

DomesticInternational

What degree or program are you studying? *

What school is your program under? *

Current Concerns

Please briefly describe your current concerns and what you would most like to accomplish by accessing support *For example, stress, anxiety, family issues, procrastination, academic problems, financial difficulties

Have you seen a Wellbeing Advisor or Counsellor at Student Wellbeing before? *

YesNo

Are you wanting to:

Return to counselling and see the same counsellor I saw previouslyReturn to counselling but see a different counsellorI need help with a different issue and/or would like to speak with a Wellbeing AdvisorI'm not sure

Are you currently seeing a Psychologist or Counsellor? *

YesNo

Where is your psychologist or counsellor based?

Student Wellbeing at University of NewcastleSeparate from Student Wellbeing at The University of Newcastle

Please provide further information about this support. *Who provides this support service? When was the last time you had an appointment? When are you expecting to have your next appointment?

Do you currently require any supporting documentation from Student Wellbeing? *

YesNo

Please note, the most efficient way to obtain supporting documentation for Adverse Circumstances applications is via our "Supporting Documentation Request" form.

If you would like both supporting documentation AND an appointment with a Wellbeing Advisor or Counsellor, then please complete both the Appointment Request Form (i.e. this form) and the Supporting Documentation Request Form.

Are you currently homeless or at risk of homelessness? *

YesNo

Please indicate your current circumstances. Select all that apply. *

Sleeping rough - on street, in a park etcSleeping in carCouch SurfingStaying with friends/family temporarilyHave current accommodation, but will need to move soon

Do you have current thoughts of suicide? *

YesNo

Do you have current thoughts of self harm? *

YesNo

Do you have current thoughts of harming others? *

YesNo

We are concerned about how you are feeling, given your responses to our form questions.

Please be aware, one of our team members will be in contact within 24 business hours to book an appointment, in order to develop a plan for support. You will recieve a phone call from: 02 4921 6622

If you are completing our form outside business hours, or you would like more immediate support, you may wish to engage with one of these services:

The University of Newcastle After-Hours Support Line: Call: 1300 653 007, Text: 0488 884 165

Mental Health Triage Service: Ph. 13 14 65 (Emergency mental health service)

Suicide Call Back Service: Ph. 1300 659 467

Lifeline: Ph. 13 11 14

1800 RESPECT: 1800 737 732

Please be aware that Student Wellbeing, Counselling and Psychological services is not a crisis service. If you need immediate assistance please contact one of the emergency services below:

Police/Ambulance: Ph. 000

University of Newcastle Security:

Callaghan: Ph. 02 4921 5888

Central Coast: Ph. 02 4348 4222

Port Macquarie: Ph. 0412 595 054

You can also present at any hospital Emergency Department and let them know how you are feeling (i.e. that you are having suicidal thoughts and don’t feel you can keep yourself safe). They can provide you with medical assistance in this circumstance.

Is your concern in relation to a recent sexual assault?

YesNoPrefer not to say

We are concerned about your are wellbeing and safety given your responses to our online questions.

Please be aware, one of our team members will be in contact within 24 business hours to book an appointment, in order to develop a plan for support.

You will recieve a call from: 02 4921 6622

If you would like immediate support or would like further information, other services that you may find helpful include:

1800 RESPECT: the national domestic, family violence and sexual assault phone counselling service (24 hours 7 days a week). Trained counsellors can support you to access services in your area and talk with you about your options.

Newcastle Sexual Assault Service: 02 4924 6333, 02 4921 3888

National Sexual Assault Hotline: 131 200

Victim Support Service: 1800 633 063

Rape and Domestic Violence Services Australia: 1800 424 017

We respect your decision not to discuss these concerns further at this time.

If you would like further information, other services that you may find helpful include:

1800 RESPECT, the national domestic, family violence and sexual assault phone counselling service (24 hours 7 days a week). Trained counsellors can support you to access services in your area and talk with you about your options.

Newcastle Sexual Assault Service: 02 4924 6333, 02 4921 3888

National Sexual Assault Hotline: 131 200

Victim Support Service: 1800 633 063

Is your concern related to Domestic Violence? *

YesNo

Do you have current safety concerns related to domestic violence? *

Yes No

If you have current safety concerns, what is the safest method for us to contact you? *

I will call the service on 4921 6622 when it's appropriate/safe for me (9am to 4pm Mon-Fri)Please call me at this time/phone numberPlease email me at this email addressOther

Contact time and phone number *

Contact email address *

Other contact method *

We are concerned about your are wellbeing and safety given your responses to our online questions.

Please be aware, one of our team members will be in contact within 24 business hours to book an appointment, in order to develop a plan for support via your selected safe communication pathway.

If you would like immediate support or would like further information, other services that you may find helpful include:

Victim Support Service: 1800 633 063

Rape and Domestic Violence Services Australia: 1800 424 017

Domestic Violence Hotline: 1800 656 463

The Wollotuka Institute provides academic and wellbeing/counselling support for Aboriginal and Torres Strait Islander students. Please indicate below if you would like to utilise this option.

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Your Privacy and Confidentiality Rights Explained - PLEASE READ CAREFULLY

CONFIDENTIALITY

The University is committed to the protection of your personal information. You may need to provide personal information when accessing our services and talking to a Wellbeing Advisor or a Counsellor either in person, when completing paperwork, on the telephone or online.

The University of Newcastle CAPS will not discuss your personal information with any persons outside of CAPS, except in the following situations:

When you have provided your consent;
Where the University of Newcastle has a legal obligation to do so;
Where it is necessary to manage the risk of an immediate threat of harm to an identifiable person or persons, including yourself, that can be averted only by disclosing information;
When CAPS staff are consulting or in the course of supervision or professional training (in this instance your identity and the identity of other parties involved will be concealed).

Personal information you may provide to the counselling service, including information supplied to online programs such as 'thedesk', eCliPSE, Zoom and during group programs may be collected, stored, used and disseminated by the University, for the purpose of assisting in the University's delivery of and research in respect of counselling services. Your identity, and the identity of any parties involved, will be concealed to protect your privacy.

The University of Newcastle abides by the Privacy and Personal Information Protection Act (NSW) 1998, the Health Records and Information Privacy Act (NSW) 2002 as set out in the University’s Privacy Management Plan in the collection, storage, access, use and disclosure of your personal and health information.

ONLINE AND TELEPHONE COUNSELLING

The University of Newcastle Counselling and Psychological Services also offers counselling services via telephone or online.

Our online counselling services are offered using the digital platform, Zoom.

Zoom is a free, high quality video conferencing program, which allow users to see and hear each other using a computer or handheld device that is equipped with a camera and a microphone. The University has adopted encryption processes and each Zoom meeting is password protected to reduce the risk of access by parties other than those who have been invited and to prevent potential electronic eavesdropping.

For beneficial telephone or online counselling services, you will need access to a quiet and private area away from distractions and the risk of your conversation being overheard.

For online counselling use an appropriate device with a camera, microphone and speakers, and a reliable internet service.

In consenting to using the online services you acknowledge these risks and consent to proceed with counselling and support on this basis.

LIMITATIONS OF SERVICES

Whilst the University takes all reasonable steps to ensure security in providing our services, due to reasons outside our control, the University of Newcastle Counselling and Psychological Services cannot guarantee the privacy or security of session content or communication conducted via online services (including telephone services).

There is potential that videoconferencing sessions or phone calls could be intercepted by others and communicating via these mediums cannot be guaranteed 100% secure. To ensure up to date security protocols, we recommend that you use a current version of Zoom and to ensure that your computer or other electronic device is subject to appropriate password security and up-to-date anti-virus software. Where possible, do not use public wi-fi as this is not a secure service.

Additional factors to consider include:

Online counselling may lack visual and/or audio cues, which may increase the possibility of misunderstandings.
Online counselling may have disruptions or delays in service and quality of the technology used.

It is important to consider beforehand whether this service is appropriate for your needs before proceeding.

CONFIRMATION OF INFORMED CONSENT

By engaging in online counselling services, I agree to the following:

To provide the counsellor with my location at the beginning of the session so that the online counsellor can get help in the case of an emergency.
To engage in sessions only from a private location where I will not be overheard or interrupted.
To attempt to connect to via private internet connection (i.e., not a public Wi-Fi)
To ensure that the computer or device I use has updated operating and anti-virus software.
I will not record any sessions, nor will the counsellor record sessions, without obtaining prior written consent.

I have read and understood the above statements *

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