Name
*
First Name
Family Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Phone
*
Email
Reason for referral:
*
What Poutiri service(s) will be helpful?
Maara kai support to grow your own vegetables at home
Whānau fitness classes Tū te Ihi
Tamariki & rangatahi supports, one to one & programs
Rangatahi engagement in education
Kōeke wellness program every Friday
Nursing service for whānau with chronic health needs
Pahi mobile health service & vaccinations
Mental health, addictions & counselling services
Māmā Maia breastfeeding and wellbeing support
Employment assistance
Rongoā and mirimiri services
Poutiri Wellness Medical Centre
ACC Navigation Support
Financial Mentoring
Cancer Care Navigation
Gambling support
Housing support
Rongoā Tamoko
Waiata Thursday nights
Rangatahi Wednesday nights
Please choose Referral Type:
*
Referral for myself or my child (under 16 years)
Referral for a family member or friend
If you are referring for a friend or family member, do they know and agree you have referred them?
*
YES
NO
Your Name (if referring someone else)
*
First Name
Last Name
Your Phone Number (if referring someone else)
*
Please enter a valid phone number.
Format: (000) 000-00000.
Submit
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