Referral Form

We offer a range of free health, education, employment and social services to achieve the best outcome for you and your family. If you want to access our support, or you are supporting someone please complete this form. Our team will contact you within 24 hours of receiving the referral.

If you are referring yourself to access support please complete sections 1 and 2 only.

If you would prefer to download a PDF version of this form, download here (415Kb .pdf) and email it to

1. Personal details
2. Medical information
3. Referrer details

K’aute Pasifika requires you to consent to all services being provided for you and your family:

I fully understand the information given to myself/family about services offered by K’aute Pasifika.

  • I have had the Code of Health Disability Services Consumer’s Rights and K’aute Pasifika Service’s Complaints process explained / given to me.
  • I understand I have the right to decline or withdraw from K’aute Pasifika Services at any time.
  • I understand that all information and records will be kept confidential, and will only be discussed with appropriate agencies following consent, unless there are concerns about the safety of a child or other family members. In this situation information may be shared with appropriate agencies.
  • I understand that non identifying information may be used for auditing, reporting and research purposes to monitor and improve K’aute Pasifika Services.

I consent for my family (including children under the age of 18 years), and those living away from my home to the following:

  • Utilisation of services provided by K’aute Pasifika in areas of health, education and social services and the sharing of information with the appropriate services that will benefit myself my family well being * K’aute Pasifika staff to organize, facilitate meetings that would involve me and family with agencies
  • Participation in research in areas of health, education and social services.
  • I understand I have the rights to decline/withdraw from K’aute Pasifika Services any time.