Fields with an asterisk (*) are compulsory.

What is their gender?*
Will another referral from your GP, Counsellor, Mental health worker be sent to us?*
Does the person agree to you making this referral?*
If this person is a minor are they in your care?*

If someone is in immediate danger, please dial 111 for ambulance assistance. Or phone your local DHB Mental Health Crisis Team (CATT Team), for a list of numbers call Healthline 0800 611 116

If you prefer, you can download a printable form for emailing here.
Email your completed form to:

For help in a Crisis:


For more information about helping family / whānau:

Do you need support?

Supporting Families in Mental Illness is an organisation that helps families and whānau to provide the best possible quality of life and recovery to their loved one who has a mental illness and to their own self-care. Call 0800 732 825, Monday – Friday 8.30 until 5 pm.


For any referrals coming through from medical or counselling professionals, please have these either faxed (09 849 2375) or emailed to Thank you and we will be in touch shortly.

Copyright © 2020 Anxiety New Zealand Trust

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