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Police referral form

Enquiry form for police

If you are from the police and would like to refer someone to our services, please complete our police referral form.

Thank you for your referral!

We've received your referral and will get back to you as soon as possible.

If this is an urgent matter, please call us directly.

Referrer Details (Police Officer)

Your full name

Your phone number

Your email address

Your organisation (if applicable)

Your role or relationship to the young person

Have you spoken to the young person about this referral?

Yes No

Young Person's Contact Details

Full name of the young person

Preferred name

Phone number

Email address

Preferred way to contact them

Phone Text Email No preference

Best time to contact

Morning (8am–12pm) Afternoon (12–5pm) Evening (5–9pm) Anytime

Is this urgent?

Yes No

Young Person's Details

Where are they located?

Date of birth

Gender

Ethnicity (tick all that apply)

Māori NZ European / Pākehā Pasifika Asian Other

Pronouns

She/her He/him They/them Other

What school or alternative education facility do they attend?

Support and Consent

What support are they looking for?

Crisis support Counselling ACC therapy Group support Court support Not sure

Have they accessed HELP services before?

Yes No Not sure

Are you their legal guardian?

Yes No

If you are not their guardian, do they know about the referral?

Yes No

Do you have concerns about safety or consent we should know about?

Is there anything else you'd like us to know?

Something went wrong

Please try again or contact us directly.

Refer friends or whānau

If you know a loved one who needs our HELP, you can fill in our form and refer them to our services.

Fill in our form

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Your donation helps us meet the ever-increasing demand for our services and support us so we can be there for survivors and their loved ones when they need us.

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