Refer myself | Te Waharoa

Te Waharoa Referral Form

Self-Referral

My Details

First name

Last name

Date of birth

Ethnicity and iwi (if applicable)

Preferred pronouns:

She/Her

He/His

They/Their

Other

Address

Phone

NHI (if known)

GP / Medical Centre

Emergency Contact

Emergency contact name

Relationship to me

Emergency contact phone

Referral details

Which service(s) or programme(s) are you interested in?

How can we support you or your whānau?

Are you currently receiving support from any other services/professionals? (If yes, please provide further details if you can.)

Is there anything else you would like us to know?

I am...

Smokefree

Not smokefree and interested in support to become smokefree

Not smokefree and not interested in support to become smokefree

Consent

Information: I agree that my information may be shared with other staff of Purapura Whetu for the purposes of my participation in Te Waharoa activities.

Photography & Video: I understand and agree that any photographs, videos or other images taken of participants during activities associated with Purapura Whetu may be used for promotional purposes of similar activities, including material on websites, social media, and other advertising.