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Get In Touch

I am touching base on behalf of
Name
D.O.B
Email Address
I'd like to enquire about

This form should be used by external agencies to professionally submit a referral to Whatever. If this doesn't apply to you and you just want to make contact with Whatever for help, please select 'myself' in the above field.

Thank you for reaching out to us. We aim to respond to your message within 2 working days.

For immediate assistance:
Medical Emergency: Please call 111 or visit Whanganui Accident and Medical.
Alternatively, you can phone the health line for advice 0800 611 116
Mental Health Emergency: Please call 111 or contact the crisis team at 0800 653 583.

Your safety and well-being are our top priorities. If you need urgent help, don't hesitate to reach out to the appropriate services.
Oops! Something went wrong while submitting the form. If you haven't
checked the required disclaimer and require urgent medical help,
please call 111 or for mental health support, call Whanganui
Mental Health on 0800 653 358.
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referrer details

Name
Agency
Contact Number
Email Address

client's details

Name
Date of Birth
Contact Number
Gender
Ethinicity

Referral

Has this young person talked to someone about this before?
Is this young person willing to talk to someone at Whatever?

Signed by

Referrer
Date
Young Person
Caregiver
Thank you! Your submission has been received!
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