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Make a Referral

If you would like to refer yourself or someone else to our service, please complete the Referral Form below. If you have any questions or need help to complete a Referral Form, please contact us.


Once we receive a referral, we will contact you within five business days (usually within 1-2 business days).

Referral Form

What would you like to do?

Referrer Details

Client Details

Does the client speak English?

Contact Details

GP Details

Emergency Contact Person

Support Needed

Is the client affected by the March 15 terrorist attacks?
Please select support needed:
Please select any of the following services that the client is currently accessing:
Are you and your whānau (family) smokefree?

File Upload

Upload File

COVID-19 Vaccination Status

You do not need to be vaccinated to access our services, however, your vaccination status may affect the way our services are delivered (e.g. numbers for group programmes etc). Please select one of the following options:


Thank you for referring to Muslim Wellbeing Ōtautahi.

One of our team will be in touch as soon as possible.

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