Find Help, Support or make a referral.

Start your request to receive support.

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Before you start

This form helps us understand what support you are looking for. We use your answers to match you with the right provider. You can share as much or as little as you feel comfortable with.

This form should take no more than 8 minutes to complete and submit.

Are you safe right now?

1. Are you (or the person you are referring) safe right now?*

Yes

We are not a crisis service and this form is not monitored 24/7. If there is immediate danger, please call 111 or the mental health crisis team at Health New Zealand Mental health crisis assessment teams.
For further support call one of the services below:

Safe to talk: 1737 (24/7)
Healthline: 0800 611 116
Lifeline: 0800 543 354 or text 4357
Suicide Crisis Helpline: 050 882 8865
Mental Health Foundation

(You can still continue the form.)

2. Who is this referral for?*

I am referring myself

I am referring someone else

Has the person agreed that you can share their information with us?*

Yes

We need their consent to continue. We are not a crisis service and this form is not monitored 24/7. If you are worried about their immediate safety, please call 111 or the mental health crisis team at Health New Zealand Mental health crisis assessment teams.

For further support, call one of the services above. services above.

Who is the referral for?*

An adult

A child or young person under 16

Details of person seeking support

Contact Details

Full name*

First Last

Date of birth*

MM slash DD slash YYYY

Phone number*

Email Address

City/Town

Region

Details of person referring someone else

Full name*

First Last

Relationship to the person*

Family / whānau

Friend / support person

Professional

Other

Phone number*

Email Address*

What support are you looking for?

This helps us find the right health professional for you. If you’re unsure, that’s okay.

Tell us what support you are looking for?*

ACC Sensitive Claims

Counselling

Psychology

Supervision

Equine Therapy

Group Therapy

Psychological Assessment

Psychiatry

Coaching

Cultural Advice

Not sure / help me choose

You can choose more than one option.

2. How would you like to meet with your health professional?*

In person

Online (video)

Phone

No preference

Support Needs

4. Funding (Optional)

ACC

Private / selffunded

Employee Assistance Program (EAP)

Other (please specify)

Not sure

a) Do you have any needs we should know about to support you well?

Yes

(For example: mobility, hearing, language, learning needs)

Please tell us

b) Is there anything about your culture, identity, or background that would help us support you better?*

Yes

Please tell us

c) Do you have any preferences for your health professional?*

Yes

(For example: gender, language, kaupapa, approach)

Please tell us

Tell us a little about what’s happening.

1. What would you like support with right now?*

2. What are your main concerns?

Anxiety or worry

Depression

Stress

Relationships

Trauma

Grief or loss

Work-related concerns

Identity or cultural concerns

Other

Tick any that may apply.

Please specify

Safety Check

Some people have difficult or worrying thoughts when they are under a lot of stress. These questions help us understand how to support you safely.

a) Are there any safety concerns we should know about right now?

Yes

What are you worried about

Thoughts about harming myself

Thoughts about not wanting to be alive

Worries about hurting someone else

Feeling unsafe because of someone else

Substance use

Other (optional)

Choose as many as required.

Consent and Privacy

Consent*

I agree that South Coast Psychology can collect, use, and securely store my information to review my referral and match me with a suitable health professional, in line with their Privacy Policy.

Consent*

I am completing this referral by choice, and the information I have provided is true to the best of my knowledge.

Consent*

I agree that South Coast Psychology may contact me by phone, text, or email about this referral and next steps.

Consent*

I understand my information is confidential, except where sharing is required by law or needed to prevent serious harm.

Consent*

I understand consent is ongoing and can be withdrawn. I understand my health information is kept for a period of time (usually 10 years) and I can ask to see or correct my information.

Consent*

I agree that relevant information from this referral may be shared with a suitable health professional for the purpose of offering services and supporting my care and safety.

Consent

I confirm I am the child or young person’s parent or legal guardian, or have legal authority to give consent.

Consent

I consent to South Coast Psychology collecting and using the child or young person’s information to review this referral and arrange appropriate support in line with their Privacy Policy.

Consent

I consent to being contacted about this referral and next steps.

Consent

I consent to relevant information being shared with a suitable health professional to support the child or young person’s care and safety.

Consent

I understand the child or young person will be involved in decisions about their care in a way that suits their age and understanding.

Consent

I understand consent is ongoing and can be withdrawn. I understand my health information is kept for a period of time (usually 10 years) and I can ask to see or correct my information.

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