- KotahiConnect

West Coast Health Youth Clinic - Youth Clinic - Youth Clinic Referral

Ensure all mandatory fields are filled in before submitting the form.

Self-Referral Referring yourself, or your whānau

Service Provider Referral Referring one of your clients.

Referrer Details

Provider Details

First Name

Last Name

Organisation Name

Contact Details

Phone Number

Email Address

Address

Physical Address

Address 1

Address 2

Suburb

City

Post Code

Postal Address is the same as Residential Address

Client Details

Personal Details

First Name

Middle Name(s)

Surname

DOB

NHI

Gender

Ethnicity1

add another

Contact Details

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Other Phone

Email Address

Address

Residential Address

Address 1

Address 2

Suburb

City

Post Code

Postal Address is the same as Residential Address

Referral Details

Note: One of our team will reach out to arrange a booking time that suits.

Reason for referral (NOTE: This is optional)

Preferred Appointment Times

Choose who you would like to see.:

Nurse Practitioner Mental Health Clinician

Please indicate a time that will suit you best.
You will receive a confirmation via text or a phone call within one day from Monday to Thursday. If it is a weekend please expect a text or phone call on the next working day.

2:30pm

3pm

3:30pm

4pm

4:30pm

5pm