PĀTAI MAI ENQUIRIES Fill out this form for the next step in the referral process. We will be in contact with you in the next 5 days. Name * The name of applicant for the referral First Name Last Name Gender: * Male Female Gender diverse Non-binary Ethnicity: * Māori New Zealand European Pacifica Other Email: * Please put correct contact details Phone: * Please put correct contact details (###) ### #### Are you enquiring for yourself? * Yes No Agency application What is the specific reason: * Tick the ones applicable to you Anxiety Depression Self-harm Low mental health Emotional regulation issues Relationship issues Safety issues Domestic violence Family violence Sexual abuse/harm Psychological/emotional abuse Historical trauma Mood swings Lack of support Social stressors Low self-esteem Environmental issues Parental separation Anger management Conflict Resolution Neglect Identity considerations Attachment/abandonment issues Thank you for your submission, we will respond to you within 5 working days. Click here for resourcesIf you are in need of immediate services or if there is an emergency you can contact:Need to Talk? 1737, Emergency mental Healthline (0800 112 334), 111 Emergency Services
