Contact Us — Te Whare Tane

We'd love to hear from you

Please get in touch with us if you would like to know more about what we are trying to do or for any other inquiries

Name *

Name

First Name

Last Name

Email Address *

Phone *

Phone

Country

(###)

###

####

Subject *

Message *

Referrals

Te Whare Tane is happy to accept agency referrals / self-referrals as a first point of contact. Please feel free to fill out this form. All referrals will be held strictly confidential and will be processed as soon as possible.

Referral Form

Client Name *

Client Name

First Name

Last Name

Client Address *

Cell Phone Number *

Home Phone Number *

Current Accomodation *

Own Transport *

Yes

No

Significant Recent history of drug or alcohol abuse *

Yes

No

Significant Recent history of cognitive or mental health condition *

Yes

No

Previous family violence or assault charges *

Yes

No

Previously attended a "Stopping Violence Programme" *

Yes

No

Currently Employed *

Yes

No

The Client is willing to undertake

2 x 3 Hour initial assessment and orientation *

Yes

No

10 x 2.5 Hour group meeting or counselling sessions *

Yes

No

Perceived Risk of Harm

To Self *

Low

Medium

High

To Family / Whanau *

Low

Medium

High

To Others *

Low

Medium

High

To Property *

Low

Medium

High

Additional Information

Referring Agency & Contact Name *

Contact Phone Number *