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

Referral sent.

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

For help in a Crisis:

If you are worried about the safety of a loved one, or someone else you can call the Crisis Team on 0800 800 717 or dial 111 in an emergency. 


For more information about helping family / whānau:

Do you need support?

Formerly known as Supporting Families NZ, Yellow Brick Road is a national organisation that provides support for whānau who have a loved one experiencing mental health challenges. Mental health support for families - Yellow Brick Road


For any referrals coming through from medical or counselling professionals, please have these either faxed (09 849 2375) or emailed to