Make a referral
Please select which service you are making a referral for.
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People for Us
Haerenga Motuhake
Tiaki Rangatira - Elder Abuse Response
Te Ara Tūhono - ACC Navigation support
Rongoaa
ACC Living my Life
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People for Us
Who is completing this form?
*
This referral is for myself
This referral is for someone else
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People for Us - About Me
My first name
*
My last name
*
My gender
*
Female
Male
Gender diverse
Prefer not to say
Other
My Date of birth
*
-
Month
-
Day
Year
Date
My disability
*
Physical
Learning / Intellectual
Sensory
Autism Spectrum Disorder
Other
My Ethnicity
*
Māori / Tāngata whaikaha Māori
Pacific Peoples / Tagata Sa’ilimalo
NZ European / Pākehā
Asian
MELLA
Other
My Street Address
*
The City/Town I live in
*
My Postcode
I have a power of attorney?
*
Yes
No
Unsure
If you have a power of attorney please put their name and phone number below
What is the best way for you to understand information?
*
Verbal
Written (large print)
Easy Read / Plain language
Sign language
Interpreter needed
Other
If an interpreter is needed, what language?
Please briefly describe the reason for seeking People for Us assistance
*
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Residential provider details
Name of provider
*
Residential provider contact number
*
Residential provider email
Residential provider address
Can we contact the residential provider?
*
Yes
No
Unsure
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People for Us - About them
Their First Name
*
Their Last Name
*
Their gender
*
Female
Male
Gender diverse
Prefer not to say
Other
Their Date of Birth
-
Month
-
Day
Year
Date
Their disability
*
Physical
Learning / Intellectual
Sensory
Autism Spectrum Disorder
Other
Their Ethnicity
*
Māori / Tāngata whaikaha Māori
Pacific Peoples / Tagata Sa’ilimalo
NZ European / Pākehā
Asian
MELLA
Other
Street address of where they live
*
Their City/Town
*
Their Postcode
Do they have a Power of Attorney?
*
Yes
No
Unsure
If they have a Power of Attorney please provide their name and contact information below
What is the best way for them to understand information?
*
Verbal
Written (large print)
Easy Read / Plain language
Sign language
Interpreter needed
Other
If an interpreter is needed, what language?
Please briefly describe the reason for seeking People for Us assistance
*
Name of their residential provider
*
Contact information of their residential provider
*
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About the person filling in this form (person making the referral)
Your first name
*
Your last name
*
Your relationship to the person
*
Your organisation (if applicable)
*
Your phone number
*
Your email
*
Does the person know you are making a referral on their behalf?
*
Yes
No
Please briefly describe the reason for seeking assistance from Te Ahi Kaa
*
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Haerenga Motuhake
I am making this referral for
*
Myself
Someone else
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Haerenga Motuhake - About me
Your first name
*
Your last name
*
Your phone number
*
Your email
*
Your home address
*
The town/city you live in
*
My gender
*
Female
Male
Gender diverse
Prefer not to say
Other
Your preferred pronouns
My ethnicity
*
Māori / Tāngata whaikaha Māori
Pacific Peoples / Tagata Sa’ilimalo
NZ European / Pākehā
Asian
MELLA
Other
My Date of Birth
*
-
Month
-
Day
Year
Date
Whānau Awhi - Please share who your support people are.
Please briefly describe the reason for seeking assistance from Te Ahi Kaa
*
If you have an ACC claim number please share it below
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Tiaki Rangatira - Elder Abuse Response
Who is completing this form?
*
This referral is for myself
This referral is for someone else
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Tiaki Rangatira - About me
Your first name
*
Your last name
*
Your phone number
*
Your email
*
Your home address
*
The town/city you live in
*
Your gender
*
Female
Male
Gender diverse
Prefer not to say
Other
Your preferred pronouns
Your ethnicity
*
Māori / Tāngata whaikaha Māori
Pacific Peoples / Tagata Sa’ilimalo
NZ European / Pākehā
Asian
MELLA
Other
Your Date of Birth
*
-
Month
-
Day
Year
Date
Whānau Awhi - Please share who your support people are.
Please briefly describe the reason for seeking assistance from Te Ahi Kaa
*
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Next
Save
Te Ara Tūhono - ACC Navigation
Who is completing this form?
*
This referral is for myself
This referral is for someone else
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Save
Te Ara Tūhono - About Me
Your first name
*
Your last name
*
Your phone number
*
Your email
*
Your home address
*
The town/city you live in
*
Your gender
*
Female
Male
Gender diverse
Prefer not to say
Other
Your preferred pronouns
Your ethnicity
*
Māori / Tāngata whaikaha Māori
Pacific Peoples / Tagata Sa’ilimalo
NZ European / Pākehā
Asian
MELLA
Other
Your Date of Birth
*
-
Month
-
Day
Year
Date
Please share your ACC claim number if you have one
Please briefly describe the reason for seeking assistance from Te Ahi Kaa
*
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Rongoaa
Who is completing this form?
*
This referral is for myself
This referral is for someone else
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ACC Rongoaa - About Me
Your first name
*
Your last name
*
Your phone number
*
Your ACC Claim number
Your email
*
Your home address
*
The town/city you live in
*
Your gender
*
Female
Male
Gender diverse
Prefer not to say
Other
Your preferred pronouns
Your ethnicity
*
Māori / Tāngata whaikaha Māori
Pacific Peoples / Tagata Sa’ilimalo
NZ European / Pākehā
Asian
MELLA
Other
Your Date of Birth
*
-
Month
-
Day
Year
Date
Please briefly describe the reason for seeking assistance from Te Ahi Kaa
*
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Next
Save
Living my Life
Who is completing this form?
*
This referral is for myself
This referral is for someone else
Back
Next
Save
Living my Life - About Me
Your first name
*
Your last name
*
Your phone number
*
Your ACC Claim number
Your email
*
Your home address
*
The town/city you live in
*
Your gender
*
Female
Male
Gender diverse
Prefer not to say
Other
Your preferred pronouns
Your ethnicity
*
Māori / Tāngata whaikaha Māori
Pacific Peoples / Tagata Sa’ilimalo
NZ European / Pākehā
Asian
MELLA
Other
Your Date of Birth
*
-
Month
-
Day
Year
Date
Please briefly describe the reason for seeking assistance from Te Ahi Kaa
*
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