Referring someone

Connect yourself or someone you know or work with to specialist support from Canteen

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We need a few details so that we can provide you with the best possible support. Once you submit the form, someone from the Canteen Services team will be in touch as soon as possible (within 5 working days) to discuss support options. Please note that Canteen does not provide a crisis service. For emergencies, please contact 111 or for mental health advice and support please free text 1737.

Please select if you are...

Rangatahi Details

Pronouns *

If other, please share the pronouns of the rangatahi

First name *

Last name *

Date of birth *

Ethnicity *

If other, please share ethnicity

Mobile number

Email address

Address *

Address 2

City/Town *

Post Code *

Are you 18 years or older?

Please select Yes or No *

Emergency Contact Details

First Name *

Last Name *

Mobile Number *

Email *

Relationship to you *

Rangatahi Cancer Experience

What best describes cancer experience? *

Enter other...

Cancer Type *

Reason for referral *

Do you have any urgent mental health needs or is there anything putting you at risk at present? *

How did you hear about us? *

Referrer Details

Your first name *

Your last name *

Your email address *

Your mobile number *

Your organisation *

Your role *

Rangatahi Details

Pronouns *

If other, please share the pronouns of the rangatahi

First name *

Last name *

Date of birth *

Ethnicity *

If other, please share ethnicity

Mobile number

Email address

Address *

Address 2

City/Town *

Post Code *

Rangatahi Consent

Has the rangatahi given consent for this referral? *

Rangatahi Emergency Contact

First name *

Last name *

Mobile number *

Email address *

Relationship to rangatahi *

Does the rangatahi live with their parent/guardian? *

Rangatahi Cancer Experience

What best describes cancer experience? *

Enter other...

Cancer Type *

Reason for referral *

Are there any risk or safety concerns we should be aware of? *

Other details?

Referrer Details

Relationship to rangatahi *

Your first name *

Your last name *

Your email address *

Your mobile number *

Rangatahi Details

Pronouns *

If other, please share the pronouns of the rangatahi

First name *

Last name *

Date of birth *

Ethnicity *

If other, please share ethnicity

Mobile number

Email address

Address *

Address 2

City/Town *

Post Code *

Rangatahi Consent

Has the rangatahi given consent for this referral? *

Rangatahi Emergency Contact

First name *

Last name *

Mobile number *

Email address *

Relationship to rangatahi *

Does the rangatahi live with their parent/guardian? *

Rangatahi Cancer Experience

What best describes cancer experience? *

Enter other...

Cancer Type *

Reason for referral *

Are there any risk or safety concerns we should be aware of? *

Other details?

How did you hear about us? *

IMPORTANT NOTE:

Due to a technical issue, we were unable to retrieve any submission data sent between 1–8 July 2025.

If you submitted a form or enquiry during this time, please get in touch with us directly so we can make sure your information is received. You can contact us at info@canteen.org.nz or call 0800 2268 336.

We’re sorry for the inconvenience and appreciate your understanding.