Waypoint Introduction – Short Form

Please fill in the details below.

Please note: Waypoint and our Service Providers are not emergency services and do not provide crisis support. In case of emergency, please call 111 for support. For mental health crisis phone numbers, click here.

Referrer's Full Name

Referrer's Organisation and Title

Referrer's Email Address

Referrer's Mobile Number

Client Information: Name

Last Name

Preferred Name & Pronoun

Date of Birth

NHI (if available)

Home Address

Contact Number

Ethnicity

Emergency Contact: Name, Mobile number, Relationship?

GP Details (if available)

Does the Young Person Consent to Waypoint having their details?

Does the Young Person know we will contact them directly?

Do you already have Waypoint Services in mind for the Young Person? Visit our website for a list of the services we provide. See 'How we can help' button below this form.

About your Young Person: i.e, 5 P’s: Predisposing, Precipitating, Perpetuating, Protective and Presenting

Current and immediate risk factors

Address

Message Sent.

How we can help

Get in touch

askme@waypoint.org.nz

0800 WAYPOINT
0800 9297 6468
Hours
Monday to Friday - 8:30am - 4:30pm