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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

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Gender Diverse

Phone Number

Email

Do you have any concerns about your safety?

Yes

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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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