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arc Counselling Services

Addiction Resource Centre

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0800 227 5272

Referral Form

First name*

Last name*

Address*

City/Town

Postcode:

Phone*

Email*

Birthday*

Day

Month

Year

Age*

Ethnicity*

European

Maori

Pacific Island

Other

Other:

Iwi/Hapu

NZ Citizen

Yes

No

NZ Resident Visa

Yes

No

Referral Source*

EMERGENCY CONTACT: Name:

Mobile:

Relationship:

To assist us to give the best help please tell us what the problem is related to:*

Nicotine

Huffing

NZTA

Gaming

Alcohol (only)

Vaping

Drugs

A & D

Gambling

Other

Days available?*

Preferred appointment contact method*

In person

Phone

Zoom

Signature*

Date:*

Referral Form

0800 227 5272

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