Enquiry - adult | Wellington Sexual Harm Help

Your Details

Your full name

Your phone number

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How do you know the person you are referring?

Your agency

Preferred way to contact you

Phone Text Email No preference

Best time to contact you

Has this person given consent for this referral?

Yes No

Their Contact Details

Their full name

Preferred name

Their phone number

Their email

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Phone Text Email No preference

Best time to contact

Is this urgent?

Yes No

About Them

Where are they located?

Their date of birth

Their gender

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Their pronouns

She/her He/him They/them Other (please specify)

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Referral Background

Time Frame

Acute Recent Historic

Please provide brief detail (if known)

Please provide full details agency, worker and nature of historic involvement

Risk Profile

Are you aware of any of the following (current / recent)?

Please provide details

Current safety concerns - please detail all known current risks to safety and welfare

Current safety plan - details of current safety plan, including details of people / agencies involved

Current mental health status - please include medication details, if known

Support Needs

Have they accessed HELP services before?

Yes No Not sure

Is there anything else you want us to know?

Adult referral form