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Ka Pou Whenua Referral

Ka Pou Whenua Online Referral Form

Important: (Required)

This online referral form should only be completed if a phone call has been made to Ka Pou Whenua and accepted over the phone first.

Referrer Details

Organisation:
Phone:
CR ACNM 021 598 602
Other
Email:
cdhb-mhcr@cdhb.health.nz
Other

Tangata Whaiora Details

Birthday
Gender
Female
Male
Non-Binary
Text message okay?
Yes
No

Next of Kin/Contact Person

Referral Details:

Does the person have a current or historical mental health diagnosis?
Are there other services currently involved with this person?
Does the Whaiora have a current safety plan?
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Kā Pou Whenua is lead by Purapura Whetu Trust and Poutini Waiora. 
All rights reserved 2025.

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