Heart Collective Referral Form
The purpose of this form is to gather enough information about you so that we can assess your needs and  identify available funding.  We will triage and get back to you usually within three business days. 

We do not hold waitlists, we will refer based on availability at the time of your enquiry.
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If you are completing this referral for yourseIf please type SELF below. If this referral is being made on behalf of the client, please provide your name and relationship to the client. By completing this form you confirm the client is aware that this referral has been made. *
Client Name *
Date of Birth *
MM
/
DD
/
YYYY
Ethnicity *
Gender *
Phone number *
Email Address *
Session Type preferences? You can select as many as you like *
Required
Contact Preference *
I consent to my contact details being passed on to the Heart Collective therapist to contact me to arrange an appoinmtent *
If we are unable to find funding for you therapy - Are you happy to proceed Privately? If yes please advise your limit
Residential Address (please include the town/city) *
Are you able to travel for your sessions. If yes, please list where? *
Registered Medical Practice and NHI (if known) *
Are you requesting help for an ACC sensitive claim? (If you are not sure that you meet the criteria for an ACC Sensitive Claim please refer to the information under ACC on this page https://www.heartcollective.co.nz/fees) *
If yes - ACC sensitive Claim # (if known)
If this is NOT ACC - Please provide reason for seeking help at this time.
Preference for male or female therapist *
Have you ever been involved with any of the following agencies *
Required
Do you currently have any addiction challenges or medical diagnosis? If Yes please provide details *
Are you currently taking any prescribed medications or natural remedies? If yes, please provide details. *
Emergency contact - please provide the name and contact number of the person we should contact in the event of an emergency. *
I am happy for my Emergency Contact to be contacted by my therapist if they are concerned about me e.g. I do not turn up for a session and my therapist cannot contact me
 *
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