TIRIWA SUPPORT ASSEMENT FORM

1

Are you in immediate danger* This field is required.

Yes

No

2

Are you worried about yourself or someone else, that they're at risk of hurting themselves or someone else.

Me

Someone else

None of the above

3

Are you at risk of hurting yourself or someone else

YESNO

4

Are you suffering from any of the following

Depression / Anxiety

Violence

AOD

None of the above

5

Mental Health Providers

Purapura Whetu - 0800 4 94388
Mental Health Advocacy and Peer Support (MHAPS) - (03) 365 9479
Whakarongo Mai - 0800 486 923

6

AOD Support

He Waka Tapu - 0800 439 252

7

Violence Support

He Waka Tapu - 0800 439 252

Te Whare Hauora - 03 967 4673
Aviva - (03) 378 3847