Referral Form

Thank you for choosing to make a referral to Tomochology. Please complete the form below with as much detail as possible.

If you are under 16, we require consent from your parents or a legal guardian to access our service. If you are over 16, please list an emergency contact.

Your information is important and helpful to us. All information obtained via this form will remain private & confidential.

If you are worried about the safety of a friend or family member, please contact Palmerston North Crisis Team 24/7 at 0800 653 357 for urgent support. If you believe that you or someone else is in immediate risk, call 111.

Preferred contact method

I am making this referral for

First name

Last name

Preferred name (to be used when we contact you)

Date of Birth

Ethinicity

Gender

Email address

Mobile number

Detailed reasons for referral

Other agencies/support involved

Emergency contact (Name and Phone/ Email address)

Consent from your parent/legal guardian (under 16)

If Yes, name and contact details of your parent/legal guardian

Address

Message Sent.