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Addictions Recovery Hawkes Bay Online Referral Form

Section 1:  Your details

Let us get to know you a little.  Tell us some basic details about you

Now let us know how to best get back to you

How do you prefer to be contacted?
Section 2:  Your Current Status is

Let's find out a little more about you and what your current status is

Have you been Referred by another agency?
Are Next of Kin/Family/Whanau aware of and support this referral?
Do you have any children under 14 in your care?
Any Pending Charges with the courts?
Any difficulties with reading/writing/memory?
Section 3:  How we can support you?

Nearly done!  We just need some details on how we can best help you achieve your goals

What substance/s are you (or have you) been using
?

What service/s would you like to attend *

See "Addiction Recovery Programmes" for a detailed description of each of the listed services
Section 4:  Finishing up!

We think we've got everything we need, but if we've missed something, please do let us know.  When you're satisfied there's nothing else to add, hit the submit button to get things underway

Supportive Documents - Upload File

Thanks for submitting!

Someone from our Hawkes Bay Team will be in contact with you.

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