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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

Whaiora (client) Details

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


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