Mental Health and Addictions Hawkes Bay Online Referral Your Details Current Status How We Can Help Finishing Up Url Section 1: Your Details Let us get to know you a little. Tell us some basic details about you Legal First Name * Legal Last Name * Preferred Name NHI Number (if Known) Date Of Birth * Gender * Ethnicity * Iwi Now let us know how to best get back to you. Street Address * City * Post Code (If Known) Primary Contact Number * Secondary Number Email Address How do you prefer to be contacted? * Phone Email Section 2: Your Current Status Let's find out a little more about you and what your current status is Have you been Referred by another agency? Yes No Next Of Kin Details Are Next of Kin/Family/Whanau aware of and support this referral? Yes No Who is your GP? Any Mental Health issues (please state) Any Medical Concerns or Allergies (please state) Do you have any Children under 14 in your care? Yes No Any Pending Charges with the courts? Yes No Any difficulties with reading/writing/memory? Yes No Section 3: How we can help 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 been) using? Substances Used Alcohol Benzodiazepines Cannabis IV Drug Use LSD/Hallucinogens Other Drug/Substance Substances Used Meth/amphetamines Opiates Solvents Synthetic Highs Tobacco What service/s would you like to attend * Support Groups Residential Programme Community Day Programme I'm not sure See "Services We Provide" Below 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 How did you hear about our service? Anything else you'd like to add?