DBT Enquiry Form

1
Please note:

All data collected from this enquiry form is considered confidential, kept in our service database and unless an information release form is explicitly provided, this information will not be shared with anyone.

We use the information gathered from this form to help us to best respond to your enquiry.

Please work your way through the following questions and note that those marked with a red asterix require answers. When you complete the questions and select "submit", you can expect an automatic response to the email account you provide.

If you feel uncomfortable about using this form or if you don't have an email address please call (03) 525 9624 ext. 5 to speak with our Intake Coordinator.

Thank you in advance,

The DBT Team.
2
Which best describes you?* This field is required.
I am a health professional
I want to know about this service for me
I want to know about this service for a whānau (family) member or friend
3
Do you have a client in mind?
YESNO
4
Your name* This field is required.Please enter your name below.
First Name
Last Name
5
Your email address* This field is required.Please enter your email below.
example@example.com
6
Your phone numberPlease enter your land line number below, if applicable.
Area Code
Phone Number
7
Your cell phone numberPlease enter your cell phone number below, if applicable
8
Your fax numberPlease enter your fax number below, if applicable
9
Your location* This field is required.Please enter the nearest city/township to you
10
Are you currently receiving treatment?* This field is required.Please confirm if you are working with a professional at the moment
YESNO
11
What kind of treatment provider/s are you working with?* This field is required.Please select which options apply to you, you can select multiple options
DHB Mental Health Clinician
ACC Accredited Clinician
Private Mental Health Clinician
GP
12
Please select appropriate* This field is required.Which best describes you; please note you can select multiple options
I work in a DHB
I am associated with ACC
I provide private care
13
Which DHB?* This field is required.Please select which DHB you work for from the dropdown box
Auckland DHB
Bay of Plenty DHB
Capital & Coast DHB
Canterbury DHB
Counties Manukau DHB
Hawkes Bay DHB
Hutt Valley DHB
Lakes DHB
MidCentral DHB
Nelson Marlborough DHB
Northland DHB
South Canterbury DHB
Southern DHB
Tairawhiti DHB
Taranaki DHB
Waikato DHB
Wairarapa DHB
Waitemata DHB
West Coast DHB
Whanganui DHB
14
OrganizationPlease let us know the name of organization you work for
15
Designation* This field is required.Please enter your position title
16
If different from designation, what is your role with your client?Let us know your role with the client, perhaps you are their case manager etc.
17
Relationship to the potential service user* This field is required.Are you a mother, a friend, an uncle perhaps? Let us know how you fit into your loved one's life
18
Potential service user's name or their National Health Index (NHI) numberIf you would like to disclose, please enter their name or NHI number. As mentioned at the beginning of this form; this information is kept confidential
19
Potential service user's location* This field is required.Please let us know the nearest city or township to where they reside
20
Are they currently receiving treatmentLet us know if the potential service user currently works with a professional
Yes
No
I'm not sure
21
Great! What kind of treatment provider?You can select multiple options. If you are unsure of their treatment circumstances, please feel free to skip ahead.
DHB Mental Health Clinician
ACC Accredited Clinician
Private Mental Health Clinician
GP
22
Enquiry* This field is required.Please let us know what you'd like to know and feel free to provide any details you feel may be helpful for us to know.
Huge
Large
Normal
Small
Ok
Ok
23
How did you hear about our service?* This field is required.Let us know how you found out about us
24
Type a question
25
Type a question
26
Type a question
27
Would you like to subscribe to our Pānui (newsletter)?
YESNO
28
29
Tags
Todo
In Progress
Done
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.