Referral Application

"*" indicates required fields

Referral to

Aukaha service the referral is for:*

Referral

Who is making this referral:*

Referred by an Agency

It's for me (Self-referral)

Date of Referral

DD slash MM slash YYYY

Referring Agency

Referring Agency Name

Your Name*

First Last

Agency Email*

Agency Phone*

Agency Address

Street Address City Post Code

Person's Details

Full Legal Name*

Date of Birth*

DD slash MM slash YYYY

Address*

Street Address City Post Code

This field is hidden when viewing the form

Email (preferably personal)*

Phone*

Best time of day to be contacted*

Morning

Afternoon

Evening

How do you prefer to be contacted*

Phone

Text

Reason for Referral*

Please detail below

Privacy Statement and Consent*

Privacy Statement for Collecting and Using Personal Information through Referral Form

This Privacy Statement outlines how we collect, use, disclose, and protect the personal information provided through our referral form, in accordance with the privacy laws of New Zealand. Your privacy is important to us, and we are committed to ensuring the security and confidentiality of your personal information.

1. Collection of Personal Information:

We collect personal information through our referral form for the purpose of processing referrals and identifying service provisions. The information collected may include but is not limited to:

Name
Contact details (such as phone number and email address)
Address
Relevant background information

2. Use of Personal Information:

The personal information collected through the referral form will be used solely for the purpose for which it was collected, unless otherwise stated. This may include:

Contacting you or the referred individual to provide requested services or information
Managing and processing referrals
Communicating updates or changes related to the referred services

3. Disclosure of Personal Information:

We may share your personal information with authorized personnel, service providers, or relevant parties directly involved in the referral process. However, we will not disclose your personal information to third parties for marketing purposes without your explicit consent.

4. Data Security:

We take reasonable measures to ensure the security and confidentiality of your personal information. This includes implementing appropriate physical, electronic, and managerial procedures to safeguard and secure the information we collect.

5. Data Retention:

We will retain your personal information only for as long as necessary to fulfill the purposes for which it was collected, unless a longer retention period is required by law.

6. Access and Correction:

You have the right to access and correct your personal information held by us. If you believe that the information we have is inaccurate or incomplete, please contact us to request corrections.

7. Consent:

By submitting your personal information through the referral form, you consent to the collection, use, and disclosure of your information as outlined in this Privacy Statement.

8. Changes to the Privacy Statement:

We may update this Privacy Statement from time to time to reflect changes in our practices or legal obligations. Any updates will be posted on our website, and the revised Privacy Statement will be effective from the date of posting.

9. Contact Information:

If you have any questions, concerns, or requests related to your personal information or this Privacy Statement, please contact us at info@aukaha.co.nz

This Privacy Statement is in line with the privacy principles set out in the Privacy Act 2020, New Zealand's primary legislation governing the collection and use of personal information.

Last updated: 23/08/2023

I have read and agree to this Privacy Statement for Personal Information

I give consent to be contacted about this referral

Referral Application

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Referral

Referring Agency

Person's Details

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