Complete our referral form to access our Refugee Trauma Recovery service. Our service is available to children, young people, and adults.  

Refugee Trauma Recovery is not a crisis service. Please refer to an emergency service if there is immediate risk of self-harm, harm to others, or acute mental health (psychosis, schizophrenia, etc.).   

We offer counselling to people from a refugee background who suffer from psychological symptoms from having experienced or witnessed torture or traumatic events before to coming to New Zealand.  

Please complete this form with as much information as possible. Fields marked with * are required. 

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Consent (required)

Is client aware of and in agreement with this referral?

Referrer details

Client details

Legal/immigration status of client?
Marital status of client?
Attending English language classes?

Client contact details

Mental health issues (required)

Adults only

Please tick the following observations or spontaneous disclosures. (you do not need to ask any questions)

Children and youth

Please tick the following observations (you do not need to ask any questions), or spontaneous disclosures

Include an acknowledgment of the client’s torture/trauma history and any other serious health concerns that could have a direct impact on their mental health e.g. living with a serious chronic condition.

Please provide details of the service and support received.

For child/youth referrals only



Do you have a copy of the Refugees as Survivors (RAS) Referral Summary?

If you have a copy of the RAS Referral Summary please email it to, and as soon as you have sent this referral. You can also fax it to 04 805 0351. Thank you.

Client cultural details

Do they want or need an interpreter?

Client family and support network details

Are there any concerns about any other family members?
Does the client have any current support networks?