Ngā Tekau Alcohol and Other Drugs Service Form

Referral to Kaupapa Māori AOD Service

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Address *

Phone *

Emergency Contact (Name) *

Emergency Contact (Phone) *

Ethnicity *

Gender

Iwi/Hapū

DOB *

NHI Number

Dependents

Referral (only fill in if not self-referral)

Referred by

Organisation

Phone

Address

Referrers role

Level of contact

Emergency Contact Details

Layout

Name

Phone

Addiction issues

How long has use been problematic?

Any other professional / Agencies currently involved?

Other relevant information

Layout

I hereby consent to the above information being made available to Ngā Tekau AOD Service *

Agree

Date

CONTACT DETAILS

Phone: 04 473 2502

Freephone: 0508 445 645

health@tekau.maori.nz

24d Marine Parade
Hīkoikoi
Petone
PO Box 39294
Lower Hutt 5045

HĪKOIKOI MANAGEMENT LIMITED EXECUTIVE OFFICE

Phone: 04 473 2502
Freephone: 0508 445 645
info@tekau.maori.nz

24d Marine Parade
Hīkoikoi
Petone
PO Box 39294
Lower Hutt 5045

WELLINGTON OFFICE

Phone: 04 801 7227

Level 1, Te Raukura (Te Wharewaka)
2 Taranaki Street
Wellington
PO Box 39294
Lower Hutt 5045

facebook

Close Menu

MENUMENU

Home
About Us
Owners Info
- - - He Kohikohinga o Ngā Waiata o Taranaki
Assets
Events
News
Publications
Ngā Tekau Alcohol and Other Drugs Service
Contact

facebook
phone
email