Referral Form

Please Note: By submitting this form you give Raukura Hauora O Tainui consent to contact you. If you are making a referral for someone else, please ensure they are aware, and to expect Raukura Hauora O Tainui to contact them directly.

All sections marked with an asterisk * are compulsory sections.

Title: *
First Name: *
Surname: *
Email: *
Date of Birth: * Age:
Ethnicity: * Gender: *
Referral made by: *
Referrers Name/Company: *
Referrers contact number: *

I would like support with the following: 

Alcohol & Drug Residential Services
Alcohol & Drug Community Services
Breast & Cervical Services
Gambling Services
Health & Well-being


Mokopuna Ora (Wellchild)
Quit Smoking
Mental Health Services
Whanau Advocacy
Oranga Ki Tua

Other Services

Main Reason for Referral                         (Please state actually service if you know their name)

Please attach your documents in a .zip file
Please write what documents have been attached:
Smoking Status: *

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