DBT Enquiry Form

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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, Chelsea Hayes.

Thank you in advance,

The DBT Team.

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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
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Do you have a client in mind?
YESNO
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Your name* This field is requiredPlease enter your name below.
First Name
Last Name
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Your email address* This field is requiredPlease enter your email below.
example@example.com
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Your phone numberPlease enter your land line number below, if applicable.
Area Code
Phone Number
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Your cell phone numberPlease enter your cell phone number below, if applicable
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Your fax numberPlease enter your fax number below, if applicable
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Your preferred method of contactPlease let us know how you'd like to be contacted
Email
Phone
Mobile
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Your location* This field is requiredPlease enter the nearest city/township to you
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Are you currently receiving treatment?* This field is requiredPlease confirm if you are working with a professional at the moment
YESNO
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What kind of treatment provider/s are you working with?* This field is requiredPlease select which options apply to you, you can select multiple options
DHB Mental Health Clinician
ACC Accredited Clinician
Private Mental Health Clinician
GP
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Please select appropriate* This field is requiredWhich best describes you; please note you can select multiple options
I work in a DHB
I am associated with ACC
I provide private care
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Which DHB?* This field is requiredPlease select which DHB you work for from the dropdown box
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OrganizationPlease let us know the name of organization you work for
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Designation* This field is requiredPlease enter your position title
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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.
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Relationship to the potential service user* This field is requiredAre you a mother, a friend, an uncle perhaps? Let us know how you fit into your loved one's life
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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
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Potential service user's location* This field is requiredPlease let us know the nearest city or township to where they reside
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Are they currently receiving treatmentLet us know if the potential service user currently works with a professional
Yes
No
I'm not sure
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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
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Enquiry* This field is requiredPlease 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.
Small
Normal
Large
Huge
Ok
Ok
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How did you hear about our service?* This field is requiredLet us know how you found out about us
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Would you like to subscribe to our Pānui (newsletter)?
YESNO
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Your experience of this formPlease use the slider to indicate your experience in using this online form
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Tags
[object Object]
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