Mind Health Intern - Client Counselling Application

Counselling Application Form

As part of a partnership with Mind Health Counselling and Bethlehem Tertiary Institute we have Karina Brocherie with us as an intern counsellor. Karina is in her 3rd year of training and will be providing RCC with 100 hours of counselling between late March and mid November 2024. Karina’s counselling hours are available to people who attend RCC, or people connected to people at RCC, and people in the communities around RCC in Riccarton.

Areas in which Karina can provide counselling - anxiety, stress, mild to moderate depression, anger, parenting/family/peer/relationship difficulties, identity and self esteem, school-related issues, study/work related pressure, death/grief, divorce/separation of parents, etc. She will also be able to undertake couples relationship counselling from mid year onwards.

Areas in which Karina can't provide counselling - Issues such as sexual or physical abuse, chronic depression, addictions, suicidal thinking, psychosis, hallucinations, eating disorders etc., need to be referred to a fully qualified counsellor.

Cost
There are no fees for these counselling sessions. However, as RCC has paid for this opportunity we do ask that users of this service do consider making a Koha payment of between $15 and $35 per session direct to RCC as Karina is not allowed under her training contract to receive Koha for her services. Please note, for people not able to afford to make Koha payments in the recommended range, Karina’s normal counselling services are still available to them.

Who sees this form?

The only RCC person who will see your request is Andrew Button, our Pastoral Care Coordinator. This is solely for the purpose of ensuring that the request is in line with the areas Karina is qualified to counsel. If confirmed, he will then send it on directly to Karina, our Mind Health Intern Counsellor to arrange a booking time with you. Any information you provide on this form will be held in the highest confidence. Please only share enough detail to enable Andrew to determine the nature of the counselling required. The details around your situation will be discussed directly with your counsellor, Karina.

Andrew will not have access to any of the counselling discussions once your form has been passed on to Karina.

Counselling Application Form

Name *

Name of person applying for counselling

Email address

We will use this to confirm we have received your application for counselling.

Phone *

Ethnicity

Is the counselling for someone aged 16 years and over? *

16 years and over

Under 16 years (Andrew will email you an information sheet and a permission form to complete and take to the first counselling session)

Did you hear about this counselling through RCC? *

Yes

If not from RCC who referred/recommended our intern counsellor to you?

Reasons for counselling / Personal background *

Any information you provide on this form will be held in the highest confidence. Please only share enough detail to enable Andrew to determine the nature of the counselling required. The details around your situation can be discussed directly with your counsellor, Karina.

I acknowledge that the counselling I/my child will receive is with Karina Brocherie, a Mind health Intern who is a trainee counsellor doing their placement at Riccarton Community Church.

I understand that everything I/my child share will be held in the strictest of confidence, the only exception being if there is potential harm to myself or harm to others. In that case, the counsellor will work with me to decide the next steps.

I will give as much notice as possible if I am unable to attend my counselling appointment. This is so the counsellor can offer the appointment to another client. Please text/ phone Karina Brocherie on 020 484 5712 or email karina.brocherie@mindhealth.org

I understand that if I/my child have any concerns about the counselling process, in the first instance I should talk to the counsellor. If the issue is not resolved I should contact the Placement Liaison Person, Hazel Prickett - Email hazel@mindhealth.org