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If you need to speak to someone immediately, please call 0800 227 233 as website referrals are only monitored weekdays between 8.30am – 5pm

OK THANKS

If you need to speak to someone immediately, please call 0800 227 233 as website referrals are only monitored weekdays between 8.30am – 5pm

OK THANKS

Self-Referral Form

Client Information

Referral by

Self-Referral

On-behalf-of

Name

What town or city are you located in?

DOB

What’s best way to contact you?

Phone

Text

Voicemail

Email

Gender

Male

Female

Gender Diverse

Phone Number

Email

Do you have any concerns about your safety?

Yes

No

Unsure

On-behalf-of Contact Information

Name

Contact Number

Relationship to client

Whanau / Family

Friend

Is your referral consented?

No

Yes

Has the incident taken place in the last 7 days?

No

Yes

BOP / Waikato
Freephone: 0800 227 233 | Tel. (07) 577 0512
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