To make a referral to our service, please enter the details below:

(please call 09 431 3459 if you are having trouble completing the form)

First Names*
Last Name*
Date of birth*
Referrer Name*
Referrer organisation*
Referrer phone*
Referrer email*
Referrer address*
Referral reason* (25 words max)
Service required*
Comments/History (100 words max):

By submitting this referral form, you acknowledge that you understand and agree to the following:

Your personal information will only be shared confidentially with agencies, people directly involved in your Wellbeing plan, if we are required by law or have serious concern about the safety of a child or young person. Anonymous information about you or your whānau/family’s service use or requests may be included in statistical summaries for the purpose of service quality, funding and contractual obligations. It will not identify any member of your family/whānau. 

We are sensitive to your privacy and will respect this in accordance with New Zealand privacy law (Privacy Act 2020).