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Enquiry Form

Enquiry form for whānau or friend

Your full name

Your email

Your phone number

Name of the person being referred

Please tick if this person has given their consent for this referral?

Which area does the person being referred live in?

Wellington

Hutt

Kāpiti

Other

If other, which area do they live in?

What is their ethnicity?

D.O.B or age (if known)

Which gender do they identify with?

What is their phone number? (optional)

What is their availability? (optional)

What is your relationship to the person?

Who should we contact initially?

What support are you looking for?

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24/7 Support line: 04 801 6655 & push 0 at the menu

Copyright Wellington Sexual Abuse Help Foundation 2022

Registered Charity: CC26255

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