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 section 1 only.

If you would prefer to download a PDF version of this form, download here (150Kb .pdf) and email it to

1. Personal details
2. Referrer details

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 the areas of health, education, employment, whanau ora and social services and the sharing of information with the appropriate services that will benefit myself my family wellbeing 
  • I understand I have the rights to decline/withdraw from K’aute Pasifika services any time.