Self-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.

Information sheet for Bereaved

Referral form downloadable

Your Self-Referral Contact Information

First name(*)

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Preferred phone number

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Email address

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Last name(*)

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Other phone number

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Address

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You give permission to be contacted (*)

Yes

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Preferred method for contact from the intake team

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Please note if there is a preferred day/time to contact within working hours

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I am already involved with this Provider

Yes

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Preferred provider (ie the person you want to receive the service from, if known)

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Demographic Information

What gender do you identify with?

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Gender details

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Date of Birth

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Preferred pronouns

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Iwi

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Ethnicity

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Ethnicity details

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Legal Guardian details if Under 16 years old

If you are 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 deceased

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Please note your relationship with the person who died below - The person who died is my…

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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 you are invovled with

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Once referral is confirmed we will try to make contact within 3 working days.

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.