Refer now

The service is for

Individuals and whānau who would benefit from brief therapeutic support focused on bereavement by suicide
Anyone bereaved by suicide at any stage in their life. Under 16 year olds will need a trusted adult to support them to participate.

Further information about the service can be found in the information sheets.

Refer now

You can refer yourself or somebody else. To refer now:

Fill in the online referral form below
Email us at referrals@aoake-te-ra.org.nz
or Leave us a message on 0800 000 053 (please leave name and contact details)

Information sheet for Bereaved

Information sheet for Referrers

Referral form downloadable

Referral Information

Referred by(*)

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Name of referrer(*)

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Phone number of referrer(*)

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Referred by details

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Email of referrer(*)

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Referrer other phone number

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Bereaved Person's Contact Information

Bereaved First Name(*)

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Home phone

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Bereaved email

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Bereaved Surname(*)

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Mobile Phone

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Address

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The bereaved has been informed about the referral and gives permission to be contacted (*)

Yes

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Preferred method for contact from the intake team

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Preferred day/time to contact within working hours

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Bereaved is already engaged with this Provider

Yes

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Bereaved's preferred provider (if known)

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Search for a Provider

Bereaved Person's Demographic Information

What gender does the bereaved identify with?

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Gender details

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Preferred pronouns

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DOB (if known)

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Bereaved age/range (if DOB not known)

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What ethnicity does the bereaved identify with?

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Ethnicity details

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Iwi

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Legal Guardian details if Under 16 years old

If the referred person is aged under 16 years, please include name and contact details of legal guardians/parents/caregivers

Full name of Guardian

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Please indicate if the guardian/parent/caregiver is aware of the referral

Yes

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Guardian email

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Please note if there is a preferred method for initial contact with the guardian

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Guardian phone

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Guardian contact preference details

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Key Information about the Bereavement

Name of loved one/person who died

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Age of person who died (if known)

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The bereaved person's relationship with the loved one/person who died - The person who died is their…

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Relationship detail

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Date of death or approximate date of death

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Any other relevant information: (eg English as a second language)

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Please note any key supports or services they are invovled with

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Once referral is confirmed contact with the bereaved will be initiated within 3 working days.

If we have been unable to connect with the bereaved within a fortnight, we will get back to you and let you know.

All information collected by Aoake te Rā is confidential and for the purposes of providing the Services as outlined. For more detailed information please see our organisational Privacy Policy.