Individual referral

Individual referral

Complete this form on behalf of yourself or someone else close to you
By completing this form you are consenting for us to collecting and storing your information. We are committed to protecting your privacy and ensuring the confidentiality of your personal information. The information we collect from you is used solely for the purpose of providing and enhancing our support services. We will not share your information with third parties without your consent, except in circumstances where we are required or permitted by law. This statement is in accordance with the Privacy Act 2020 and Health Information Privacy Code 2020.
Has the incident occurred in the last 10 days?*

YesNo
If incident occurred within 10 days contact us 24/7 on 0800 227 233 to discuss urgent assessment options
Is this referral for yourself or on behalf of another person?*

MyselfOn behalf of another person
If on behalf of, is the person you are referring aware you are contacting us?*

YesNo
Is this person under 18?*

YesNo
If they are not aware of this referral please tell us why?
eg. young child

Details of the person being referred
Name:*

First NameLast Name
Date of Birth:

DayMonthYear
Date
Gender:*
Preferred Method of Contact (select all that apply)

PhoneTextEmailVoicemail
Contact Number:*
Email*
example@example.com
What area do you live in?*

Street Address

Street Address Line 2

Area LocatedState / Province

Postal / Zip Code
What is the main reason for contacting us today?
Do you have any concerns about your safety and wellbeing / the safety and wellbeing of the person you are referring?*

YesNo
Please explain what concerns you have:
Would you like a copy of this referral emailed to you after you submit?

YesNo
Enter email address to receive a copy of this form:
example@example.com
Should be Empty: