Make a Referral

Would you like to make a referral to People for Us, for yourself or for someone else?

This form is for people who are living in residential services funded by Disability Support Services (DSS) seeking the People for Us visiting service.

Illustration of a person sitting at a desk using a computer. The screen shows a "Make a Referral" webpage with a form and a pink submit button. The person is using a mouse and appears focused on filling out the form.

We will:

read your referral carefully
take it seriously
respond in a respectful and fair way
let you know what will happen next.

Please complete this form

"*" indicates required fields

Who is filling out this form?*

I am the person living in the home

I am filling in this form for someone else

I am the person living in the home

About me

Name*

First Name Last Name

My Gender*

Male

Female

Prefer not to say

Other

My Date of Birth*

Month

Day

Year

My Disability*

Physical

Learning / Intellectual

Sensory

Autism Spectrum Disorder

Other

My Ethnicity*

NZ European / Pākehā

Māori / Tāngata whaikaha Māori

Pacific Peoples / Tagata Sa’ilimalo

Other

My Phone Number

My Email Address

What is preferred way for us to contact you?

Call

Text

Residential Address

Street Address Address Line 2 City/Town Province Postcode Country

I have a Power of Attorney

Yes

What is the best way for you to understand information?

Verbal

Written (large print)

Easy Read / Plain language

Sign language

Interpreter needed

Other

If an interpreter is needed what language?

Reason for Referral*

Please briefly describe the reason for seeking People for Us assistance

Residential Provider Details

Name of Provider*

Contact information of Provider

Can we contact your Residential Provider?*

Yes

I am filling in this form for someone else

About the person the referral is for

Name*

First Last

Gender*

Male

Female

Prefer not to say

Other

Date of Birth*

MM slash DD slash YYYY

Disability*

Physical

Learning / Intellectual

Sensory

Autism Spectrum Disorder

Other

Ethnicity*

NZ European / Pākehā

Māori / Tāngata whaikaha Māori

Pacific Peoples / Tagata Sa’ilimalo

Other

Phone Number

Email Address

What is the preferred way for us to contact them?

Call

Text

Residential Address

Street Address Address Line 2 City/Town Province Postcode Country

Do they have a Power of Attorney?

Yes

What is the best way for them to understand information?

Verbal

Written (large print)

Easy Read / Plain language

Sign language

Interpreter needed

Other

If an interpreter is needed what language?

Reason for Referral*

Please briefly describe the reason for seeking People for Us assistance

Residential Provider Details

We will contact the residential provider

Name of Provider*

Contact information of Provider

About the person filling in this form (person making the referral)

Name*

First Last

Relationship to Person*

Phone*

Does the person you are referring know the referral is being made*

Yes

Permission to share your name*

Do you give us permission to share your name with the person you are referring.

Yes

This field is hidden when viewing the form

Consent

Agreement*

By submitting I understand that People for Us will contact the person you have referred.*