Referral | Wairarapa Rape & Sexual Abuse Collective Inc.

Self referral form

Your name

Best contact number

Email address

Date of birth

Preferred way to be contacted

Best time to contact you

What support are you after

Where are you located

Have you used our service before

Is there anything else you'd like us to know

Is this an urgent enquiry

Address

Message Sent.

Friends & Whanau Referral form

Referrer name

Referrer email

Whats your relationship to the person you are referring?

Referrer contact number

Client (person being referred) name

Client D.O.B

Client contact number

Client email

Client preferred method of contact

Best time to contact

Is this an urgent enquiry?

What support are they wanting?

Has this person given consent to this referral?

Address

Message Sent.

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Contact

0800 614 614 (24/7)
06 370 8446

We are a 24/7 crisis line, however we may not be able to answer your call straight away, please leave a message for us to get back to you as soon as possible. If it is an emergency hang up and call 111. Alternatively you can submit a form under the 'Contact Us' tab if your call is not urgent & we will be in contact ASAP.

35-37 Chapel Street, Departmental Building Masterton

Office hours 8.30 AM - 2.30 PM Monday - Friday, please call as appointments are preferred