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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).

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We have been blessed over the years to be able to support members of the community with the opportunity to lean how to drive. Unfortunately we are no longer able to fund the Kia Ngātahi Driving Programme. All driving referrals will now be declined. 

Referral Form

What would you like to do?

Referrer Details

Whaiora (client) Details

Gender
Does the whaiora (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

Comments

Thank you for your referral! We will
contact you as soon as possible.

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