Referral to OutLine's Conversion Practices Survivor Network

Thanks for reaching out to get support from us! Please fill out the confidential form below and we'll get in touch you. We will make initial contact within 10 working days.

Our Conversion Practices Survivor network is for all Rainbow, LGBTQIA+, Takatāpui and MVPFAFF+ people aged 18+ who have experienced conversion practises whether that was in a clinical, faith or whānau environment.

Please note that we are not a crisis or emergency service – If you need to talk to someone right now, call or text 1737 any time to talk with a trained counsellor, or check this list of emergency contacts. You can also call our free support line, 0800 688 5463, any evening between 6 and 9 to talk to one of our volunteers.

We are running a monthly peer support group for survivors of conversion practices. We will do an initial 1-1 peer support session to find out about your support needs and work together on some wellbeing strategies and then also offer 1-1 peer support sessions as required. We also have a limited funded counselling budget so there are some people who will fit our criteria for funded sessions as well.

For needs outside of this, we aim to connect with accurate and correct information and services that will provide safe and respectful support.

Who is this service for?

All rainbow people nationwide aged 18+ who have experienced conversion practices. If we get referrals from rainbow people younger than that we will help them find support elsewhere.

What can we help with?

Our peer support group aims to give survivors a chance to connect with other survivors and in doing so let go of some of the shame, fear, pain and isolation that conversion practises create.

We hope that there will be other opportunities to connect with other survivors. We will also try to connect you with other useful services or mental health support.

Your personal information

We collect your personal information in order to allow us to get back in contact with you, enable easy information sharing between our support workers to work together on a support case, and in order to collect data around what people are accessing our services so OutLine can better advocate for gender diverse people's needs. Providing some of this information is optional, but will help us better understand your needs. We keep your information safe by storing it in password protected software and only allowing certain staff to access it. You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you’d like to ask for a copy of your information, or to have it corrected, please contact us at privacy@outline.org.nz. For more information about how we collect and use your personal information, including the information in this form, please refer to the OutLine Privacy Policy.

Are you completing this referral for yourself, or for someone else?*

For myselfFor someone else

Please tell us your name, and relationship to the person being referred for support.

E.g. parent, phone volunteer, or other professional working with the client.

Does this person know that you are referring them?

YesNoOther

How did you hear about this service?

Please complete the rest of this form as though you are the person who is being referred for peer support.

Your name*

This doesn't have to be your legal name if you use a different one

Pronouns

Age*

Ethnicities

How do you describe your gender?

E.g male, femme, Fa'afafine, transgender, genderqueer, non binary, questioning. It's okay if you would rather not say, or you're not sure.

How do you describe your sexuality?

E.g. lesbian, gay, bisexual, Takatāpui, pansexual, queer, asexual, questioning. It's okay if you would rather not say, or you're not sure.

Do you have an intersex variation?

YesNoPrefer not to sayDon't know/I don't understand the question

What city in New Zealand do you live in?

What is your phone number?

Home phone, mobile or both!

Can we leave a voicemail or send a text if you don't answer?

Yes, leave a voicemailYes, send a textNo

What is your email address?

How would you prefer we contacted you?*

Phone callText messageEmail

Do you require an interpreter (i.e. English is not your preferred language, or require a sign interpreter)?

YesNo

Tell us more about your interpreter requirements

Do you have any other accessibility requirements?

E.g. information provided in different formats, wheelchair access to venues, bringing a support person

What do you need support with?

Are you currently being supported by any other organisations? If so, which one(s)?

Is there anything else we should know?

Note that you'll need to provide either a phone number or email address before you can submit this request!