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Email: admin@thriveservices.org.nz
Phone: 0800 292 988
Fax: 03 470 1692

Referral Form

Young Person's Information

Name *

Name

First Name

Last Name

Date of birth *

Date of birth

MM

DD

YYYY

Gender *

NHI number

If known

Ethnicity *

Iwi

If Maori

Email Address

Postal Address *

Phone number *

Reason for Referral *

Please outline mental health and/or alcohol, drug concerns

Background Information

Family situation, education, accomodation, relevant history

Referrer information

If you are referring yourself just leave this section blank

Referrer Name

Referrer Agency/relationship to young person

Address

Phone

Email

Best time to contact

Does the young person know about the referral?

Do the parents know about the referral?

Help to get on track and get ahead

Thrive! Te Pae Ora is a service for young people aged 12 to 19 available in Otago and Southland.

A team of registered health professionals including counsellors, psychologists, social workers and occupational therapists work to help young people manage the ups and downs of life, reducing harm from mental health issues and drug and alcohol use.

If you think you or someone you know may benefit from a helping hand please give us a call to see if Thrive! Te Pae Ora is right for you.

Locations

Dunedin City, Clutha District & Waitaki District

Invercargill City, Southland District & Gore District

Queenstown-Lakes District & Central Otago District

Mobile Team