Piringa Application Form

In order to best facilitate your debriefing visit to us we need to know a little about you and your circumstances. Please complete the details for the following questions and press SEND. We will get back to you as soon as we can. Thanks.

PIRINGA Application Form:
Family Name: Your name is required.

Your First Name: Your name is required.

Marital Status:

Nationality:

Date of Birth:

Full Postal Address:

Contact Email Address: A contact email address is required.

Contact Phone Numbers: (incl mob if applicable)

Title/Position you currently hold:

Organisation you currently work for:

Name or title of person responsible for you in your work:

Do you work in a volunteer capacity?

Yes No

Who will pay for your visit?

If overseas, what country have you been serving in?

Length of time you have been in current position/country:

Are you taking any prescribed medication currently?

Yes No
If so, what?

Are you under the direction of a mental health professional, eg psychologist, psychiatrist or counsellor?

If a non NZ citizen, do you have travel insurance - covering personal belongings and health?

Yes No

Are you bringing your children with you?

Yes No
If so, please give their names and ages:
Children's names and ages:

Do you want your children to be debriefed?

Yes No
If not, please provide the name of the babysitter/childminder who will be coming with you to care for the children:

Please write a paragraph outlining the main reasons for requesting a debriefing at Piringa:

Your date preferences:

Please indicate your desired dates (remembering the debriefing week begins on Sunday evening and finishes midday Friday) and then give two other options of possible dates. We will endeavour to give you your first choice but this will not always be possible due to other bookings. We will get back to you as soon as possible to confirm dates

1st Choice:

2nd Choice:

3rd Choice:

Thank you! Please email us if you have any queries.