Self-Referral Forms

Physical Activity Support Service (PASS) Self-Referral Form

The PASS is a free service that supports people to become more active in a way that works for them. Whether you are looking to improve your health, help manage a long-term condition, support your wellbeing, or simply get moving again, our team can help.
PASS provides personalised support, encouragement, and guidance to help you set realistic goals and build sustainable physical activity habits.

To self-refer, please click link below and complete the form.
Conditions apply:

• As part of this referral form, you will be asked to complete a health screening questionnaire.
  Self-referral is only available for people who meet the screening criteria.
• If your responses indicate that you may need medical clearance before increasing your physical activity, you will not be able to proceed with the self-referral form and should discuss your suitability for exercise with your Primary care practice.
• If you meet the screening criteria, a member of our team will be in touch to discuss the next steps.

Congratulations on taking this positive step towards improving your health and wellbeing - we look forward to supporting you on your journey.

Dietitian Self-Referral Form

The West Coast Health Dietitian Service accepts self-referrals. It’s simple – all you need to do is fill in this form and a dietitian will be in touch.

Take advantage of this free service today.

Breastfeeding Advocate Referral Form

Breastfeeding may be natural, but that doesn’t mean it comes naturally. There are plenty of scenarios that can make breastfeeding harder and getting the right information and support is vital.

If you need help working through a breastfeeding challenge or have questions about anything related to breastfeeding, our Breastfeeding Advocate will be able to help you.

The West Coast Health Breastfeeding Advocate accepts self-referrals. It’s simple – all you have to do is fill in this form and our breastfeeding advocate will be in touch.

Take advantage of this free service today.

For more information about the Breastfeeding Advocate, click here

Youth-Mental Health Referral Form

We provide Brief Intervention Counselling for mild to moderate mental health problems, not only for adults but for youth as well, and it’s a FREE service.

Good health includes physical, emotional, mental, social, and spiritual wellbeing.  

This programme can assist rangatahi with emotional and mental fitness. We are available to cover areas coast wide from Karamea to Haast.  

You can self-refer to our programme, or can be referred by GP’s, nurses, family members or school teachers.

Please note: This online referral form is for referring youth only (12 -24 years). 

Māwhera Youth Health & Wellbeing Service Referral Form

The Māwhera Youth Health & Wellbeing Service operates every second Thursday from 2pm - 6pm at West Coast Health (Top Floor of the Speights Building, 163 Mackay Street). A Nurse Practitioner is available with the ability for drop-in appointments as well as bookings. This is a free service for Rangatahi aged 12 - 24 years old.