Referrals

If you are interested in services, for self, whānau, or a client please fill out the form on the right of this page.

referrals@gdnz.org

The Historic Village, 17th Avenue

Buildings #55

Tauranga, Bay of Plenty

Aotearoa [New Zealand]

This online Referral form can be completed by Providers, a family member, Whānau, or the individuals seeking care

Legal Name

First Name

Last Name

Identified Name

Pronouns

Date of Birth

Phone #

Address

City/Town

Suburb

Region

Area Code / Zip Code

Referral Source

Services Requested?

What services are being sought out? [transitional-care/counselling/coming-out/etc.]

NHI #

NZ NHI#s consist of 7 characters, with three letters and four numbers. There are several ways to find your NHI number, including on: --- a prescription or prescription receipt --- a prescription medicine bottle label --- a hospital letter --- an x-ray or test result --- by checking your profile on the online patient portal provided by your general practice.

Out Status

How 'Out' are you or the person you are filling this referral out for? [out to friends/partner/parents/etc.]

I understand it is my responsibility to check my email and phone [the contact information entered above] for responses from the Gender Dynamix team upon completion of this referral for their response to my referral. I understand that if I do not respond to the Gender Dynamix team, after multiple attempts to contact me regarding my referral, that my referral will be closed and I will need to make another one.

Yes, I understand my responsibility

Residency Status

Non-Resident/Citizen (no national healthcare)

Non-Resident/Citizen (national healthcare)

NZ Resident

NZ Citizen