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Hauora Self-Referral Form
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* Indicates required question
Email
*
Your email
This referral is for:
Choose
Me
Friend
Daughter
Son
Family member
Full Name
Your answer
Year Level
Your answer
I want to meet with:
Choose
Jeremy (Navigator)
Jacob (Navigator)
Bronnie (Counsellor)
Anna (Counsellor)
Nurse
On a scale out of 3, how urgent are you needing the appointment?
Choose
1 (Not urgent, I would like to be seen in the next week or so)
2 (I would like to be seen in the next couple of days)
3 (Urgent - see me today please, it is life threatening for me or for someone I know)
How would you like to be contacted?
Choose
Text message
School email
One of the Hauora team to come and get me from the hapori
If you ticked text or email for the above question, please leave your phone number or email address below
Your answer
If it feels ok to you, please write a short explanation of why you would like to meet with one of the Hauora team members
Your answer
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