Please fill out the form below to access support.
Please note we can only provide 1:1 support in Auckland, Northland, Bay of Plenty, Taranaki and Whangārei. If you're based outside of these regions, we can share information & resources or suggest local services to contact.
Which of the following applies to you?
*
I'm a young person's whānau member or partner
I'm a young person
I'm a professional referring a young person
Other
If you are making this referral on someone's behalf, please provide us with your name and contact details:
Should we contact the referrer or the young person?
The referrer (whānau or professional)
Young person
Below, please fill in some details about the person wanting support:
Name
*
First Name
Last Name
Pronouns
*
Example: they/them, she/her, he/him
Date of birth
*
-
Day
-
Month
Year
Date
Phone number
*
-
Area Code
Phone Number
Email
*
example@example.com
Based in:
*
Auckland
Northland
Bay of Plenty
Gisborne
Hawke's Bay
Taranaki
Manawatu/Whangānui
Wellington
Nelson
Tasman
Marlborough
West Coast
Canterbury
Otago
Southland
Waikato
Where in the above region does the person wanting support live?
*
e.g. Manurewa, Whangārei, Tauranga
Ethnicity:
*
Māori
Samoan
European
American
NZ European
Tongan
Nieuan
Indian
Chinese
Middle Eastern
Japanese
Thai
Korean
African
Fiji Indian/Indo Fijian
Fijian
Other
Is an interpreter required? (if English is not your preferred language, or you need a sign language interpreter)
*
Yes
No
Access to a device? (e.g. laptop, phone, computer)
*
Yes
No
Access to Zoom, Google Meet or Skype?
*
Yes
No
What would you like support with? (It's important for us to know what is most pressing so please select only 1-3 options)
*
Accessing safe and stable housing
Social transitioning (e.g. binders, clothes)
Medical transitioning (hormones, blockers)
Understanding your gender
Understanding your sexuality
Support with coming out to whānau and friends
Meeting other people like you
Help with finding other rainbow friendly services
Help with navigating school or your workplace
Information & resources
Can you tell us a little more?
*
We use the data from forms like this to report back to our funders, and communicate what we do to the wider community. Are you happy for your data to be used for research and development purposes?
*
Yes
No
I'm not sure - ask me later
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