Self-Referral Forms

Please note that our Green Prescription Service is no longer accepting self-referrals. If you would like access into these service, please make an appointment with your general practice to discuss your needs. Your GP or Nurse Practitioner will be able to make this referral providing us with all relevant information.

Please remember that you have access to a Health Coach (HC) and/or Health Improvement Practitioner (HIP) within your practice also. These are FREE appointments. HIPs or HCs can support you to make a plan and provide you with information and tools to manage your health better. 

Nutrition Self Referral Form

The West Coast PHO Dietitian Service accept self-referrals. It’s simple – all you have to do is fill in this form  and a dietitian will be in touch. Take advantage of this FREE service today!

If you want to learn more about the Nutrition Services the PHO offers then click here


Breastfeeding Advocate Referral Form

Breastfeeding may be natural, but that doesn’t mean it always 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, Breastfeeding Advocates Erin and Raewyn would love to hear from you.

The West Coast PHO Breastfeeding Advocate team accept self-referrals.  It’s simple – all you have to do is fill in this form and one of our team members will be in touch. Take advantage of this FREE service today! For more information about the Breastfeeding Advocates, click here


Youth-Mental Health Referral Form

The PHO is providing 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 youth with emotional and mental fitness. We are available to cover areas coast wide from Karamea to Haast.  Youth 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).