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Refer Now
Te Waharoa Referral Form
Note:
ALL required fields must be answered before a referral can be submitted.
We are not a crisis service. We are currently experiencing a waitlist for all one on one therapy.
I would like to:
*
Make a Self-Referral
Make a Whaanau Referral
Make a Professional/Agency Referral
Consent
*
The person I am referring has agreed to this referral being made.
Referrer's name
Referrers Details
Relationship to person being referred
Name of agency/NGO/provider
Referrer's email
Referrer's phone
Referral details
First name
Last name
Date of birth
Ethnicity and iwi (if applicable)
Phone
NHI (if known)
GP / Medical Centre
Preferred pronouns:
She/Her
He/His
They/Their
Other
Address
Email
Phone
Emergency Contact
Emergency contact name
Relationship to me
Emergency contact phone
Referral details
What Strengths do you/they already possess?
Which service(s) or programme(s) are you interested in?
How can we support you or your whānau?
Are you or the person you are referring 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
I would prefer to work with:
Male Support workers
Female Support Workers
No preference
I would prefer to be seen:
On site - In an allocated therapy space
Out in the community - Settings and venues to be discussed with my support worker
At home
No Preference
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.
Submit
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