Kia ora - thank you for landing here - we look forward to hearing from you. Simply fill in the form below, and we will be in touch. Please enable JavaScript in your browser to complete this form.Who are you filling this out for? *Select optionMyselfSomeone elseWhat is the name of the person who's looking for support? *FirstLastPlease add your name here *FirstLastAnd your gender? *Select optionMaleFemaleOtherPrefer not to sayAnd their gender? *Select optionMaleFemaleOtherPrefer not to sayWhich ethnic group(s) do you identify with? *AsianMāoriPākehā / NZ EuropeanOtherPasifikaPrefer not to sayWhich ethnic group(s) do they identify with? *AsianMāoriPākehā / NZ EuropeanOtherPasifikaPrefer not to sayWhich is their nearest town? *Select optionBell BlockEgmont VillageElthamHāweraInglewoodKapongaLeppertonManaiaMidhurstMōkauNew PlymouthNormanbyŌakuraŌkatoŌmataŌpunakePāteaPungarehuRahotuStratfordUrenuiUrutiWaitaraWaverleyWhangamōmonaOutside TaranakiPlease select their region *Select optionAucklandBay of PlentyCanterburyGisborneHawkes BayManawatūMalboroughNelsonNorthlandOtagoOutside New ZealandSouthlandTasmanWaikatoWellingtonWest Coast...And their nearest town? *Does the person you're referring consent for us to contact them? *YesNoHave you talked to them about us, and the prospect of us contacting them - and are they comfortable with this happening?Please enter their contact number *...and their email address? *EmailConfirm EmailPlease enter your contact number (double-check it to make sure it's right!) *About you (the referrer!)Your name *FirstLastYour organisation (if applicable)Relationship to the person you're referring *Your contact number (please double-check it to make sure it's right!) *...and your email address? *EmailConfirm Email...and your email address *EmailConfirm EmailPlease let us know where you're contacting us from (your nearest town) *Select optionBell BlockEgmont VillageElthamHāweraInglewoodKapongaLeppertonManaiaMidhurstMōkauNew PlymouthNormanbyŌakuraŌkatoŌmataŌpunakePāteaPungarehuRahotuStratfordUrenuiUrutiWaitaraWaverleyWhangamōmonaOutside TaranakiPlease select your region *Select optionAucklandBay of PlentyCanterburyGisborneHawkes BayManawatūMalboroughNelsonNorthlandOtagoOutside New ZealandSouthlandTasmanWaikatoWellingtonWest Coast...And your nearest town? *Arohamai - we're sorry. Sadly, there’s no way our resources can stretch that far. Additionally, our role is to work alongside other support services, collectively. Of course, there’s no way that we can do that from such a distance. We hope that somewhere in your country, there will be a community of some kind who are there for you. Don’t give up searching. Finally, please add your comment or message here. What has brought you to reach out? The more detail you can provide, the better! *Finally, please add your comment or message here. What has brought you to reach out? The more detail you can provide, the better! *Submit
