Individuals

Workplaces

Health professionals

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Physio and Rehabilitation

Physiotherapy
Hand therapy
Podiatry
Acupuncture
Concussion
Headache support
Pain management
Pelvic health

Health and Lifestyle Support

Nutrition support
Quit smoking and vaping
Fitness coaching
Sleep and fatigue support
Healthy heart support

Healthy mind

Psychology
Counselling
Sensitive claims
ADHD
EAP services

Independent living

Housing assessments
Vehicle assessments
Wheelchair assessments
Rehab at home
Social rehabilitation
Speech language therapy
Training for independence

Supporting children

Paediatric occupational therapy
Paediatric physiotherapy
Paediatric speech and language therapy

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Injury management

Prevention and training
Early intervention
Rehabilitation
Vocational rehabilitation

Occupational health

Preemployment assessment
Vaccinations
Flu vaccination programmes
Employee health and education support services

EAP support and advice

Counselling
Guidance
Health coaching
Specialised support services

Digital health services

habithealth+
The WellbeingHub

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How to refer
ACC programmes
ICP locations

Contact Habit Health

Who you are

Your enquiry

Referral type

Your details

Get in touch

How can we help you today?

I'm an individual

I'm an individual: Personal health enquiries, appointments & feedback

›

I'm a business / employer

I'm a business/employer: Workplace health enquiries or refer a staff member

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I'm a health professional

I'm a health professional: Refer a patient & general enquiries

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Individual

What brings you here?

Select the type of enquiry.

Injury referral

What type of referral is this?

Let us know whether this is a new or existing employee referral.

New employee referral

This employee has not used our services before

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Existing employee referral

This employee has previously used our services

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Your details

Fill in the form below and we'll be in touch.

ℹ️

If you're enquiring about an existing appointment, please check your booking confirmation email first.

Existing employee referral

For existing clients – you can refer your injured employee using the form below.
New customers – you can enquire or sign up to our services here.

Employee Details

Employee Name *

Job Title

Employee Mobile *

Employee Email *

Date of Birth *

Company *

Department / Branch *

Work Location / Site

Manager / Referrer Details

Manager / Referrer Name *

Manager / Referrer Phone *

Manager / Referrer Email *

What's Happening?

Which option best describes the situation? *

Experiencing pain or discomfort but still at work New injury Currently off work due to injury Struggling to perform usual duties Need help planning return to work Require ergonomic or workplace assessment Need help with injury prevention Other

Please describe

Injury Information

When did this issue start? *

Is this work-related? *

Has an ACC claim been lodged? *

Yes — ACC claim lodged No Unsure

Claim number*

Brief description of the issue

Upload files (optional)

Accepted formats: PDF, Word, JPG, PNG. Max 2 MB per file. You may select multiple files.

Desired Outcome

What outcome are you hoping for? (select all that apply)

Keep them safely at work Get them back to work quickly Clarify what duties are safe Prevent escalation Reduce absence Reduce injury rates Not sure — need advice

✦ Smart Triage Recommended Pathway

Complete the form above and we'll identify the right pathway automatically.

I confirm I am authorised to submit this referral on behalf of the employer, and that the employee has been informed their details are being shared with Habit Health.

Referral Received!

What service(s) is the referral for?

Internal/Health Partner ICP Referral Concussion Service Vocational Rehabilitation Pain Management Wound Nurse Physiotherapy Hand Therapy Acupuncture Podiatry Other

Referrer Details

Title

First Name

Last Name

Phone Number

NZ ▾

Referrer Type

Practice/Organisation Name

Today's Date

If services are declined, please notify. Referrer Other

Preferred method of contact. Phone Email

Client Details

First Name*

Last Name

ACC Claim Number - if relevant

NHI Number

Date of Birth

Date of injury

Phone Number

NZ ▾

Client Address

Additional Information

Upload any supporting files

Is there anything else you'd like us to know?

I confirm I have discussed this referral with the patient and have obtained their consent to submit it.

Integrated Care Pathway Referral

General Entry Criteria

Is there a valid ACC claim with a date of injury within the past 12 months? Yes No

Please put in the ACC45 or claim number

Current Working/Suspected Diagnosis

Use dropdown to select the diagnosis (one body part/selection only)

Area of injury

Current diagnosis

Other

Supporting Information

Investigations Undertaken: Please attach relevant reports to referral

Mechanism of injury

Was it caused by an accident? Yes No

What happened? Please provide a brief description of the accident

I confirm I have discussed this referral with the patient and have obtained their consent to submit it.

ACC Provider Referral for Concussion Service

Please note, the date of injury must be within the last 12 months, and the referral must be completed by a medical or nurse practitioner.

Client Details

Was the client employed at the time of the accident? Yes No

Is the client currently off work? Yes No

Injury Details

Date of referral

Date of injury

Date injury reported

The concussion is the principle injury an additional injury

How many times have you or another provider (if known) seen this client for this traumatic brain injury?

Glasgow Coma Scale score

Post-traumatic amnesia score

Please upload any necessary clinic notes

Is your injury diagnosis suspected or confirmed? Suspected injury diagnosis Confirmed injury diagnosis

What is your suspected or confirmed injury diagnosis?

Briefly describe how the injury occurred, e.g. the mechanism of injury.

Which of the following symptoms were present at the time of consultation? Please tick all that apply. Loss of consciousness reported Visual disturbances Loss of balance Difficulty concentrating Headaches Nausea Fatigue Dizziness Muscular aches Memory problems Mood changes (e.g. depression, anger)

List any other symptoms that are relevant to this referral.

List any pre-existing factors that may impact recovery.

If this referral includes a confirmed concussion diagnosis, it must be completed by a qualified medical professional, such as a General Practitioner (GP) or Emergency Department (ED) physician. By selecting this box, I confirm that I am qualified to make this referral.

I confirm I have discussed this referral with the patient and have obtained their consent to submit it.

Vocational Rehabilitation

Preferred key worker (if any)

Reason for referral

Injury type

Date of injury

I confirm that the patient has consented to return to work input.

Checklist Current ACC claim Employee is struggling to complete usual duties Employee has current Medical Certificate that is either FUF (Fully Unfit) or FFSW (Fit for Selected Work)

Referral likely indicated (with approval from ACC) There may be suitable alternative or light duties that the employee could do at work The employee is ready to return to work in some capacity

If the employee does not meet any of the criteria specified above but you consider that, the client would benefit from support, we can still discuss this with you and make recommendations.

Upload supporting files, such as ACC Medical Certificates, consent forms etc.

I confirm I have discussed this referral with the patient and have obtained their consent to submit it.

Nursing Services - Wound nurse referral

Gender

Current GP

Next of kin details

Date of injury

Description of injury

Please include details of recent consults/injury and any other notes for the wound nurses.

Past medical history

Medications and/or allergies

Upload supporting files

I confirm I have discussed this referral with the patient and have obtained their consent to submit it.

Form submitted

Thank you, we'll be in touch soon.

Other service

Enquire

If your workplace provides support through Habit Health EAP, including counselling, health coaching, and financial or legal advice,

Book here

Learn more

📅

Book a Physio appointment

Opens our online booking page

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Book a Podiatry appointment

Opens our online booking page

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📅

Book an Acupuncture appointment

Opens our online booking page

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📅

Book a Hand Therapy appointment

Opens our online booking page

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📅

Book a Counselling appointment

Opens our online booking page

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📅

Book a Health Coaching session

Opens our online booking page

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Get in Touch

We’d love to hear from you. Fill out the form and we’ll get back to you as soon as possible.

Your Details

Service Information

Review & Submit

Service Selection

Which service(s) are you enquiring about? *

Adult ADHD Assessment Headache Clinic Acute Concussion Clinic Housing Assessments Occupational Therapy Pediatrics Pelvic Health Appointment Psychology Appointment Speech Language Therapy VALD Performance Session Wheelchair/Seating Assessment Unsure, I'd like some guidance Other

Please select at least one service

What do you need help with? *

Please describe what you need help with

Patient Details

First Name *

First name is required

Last Name *

Last name is required

Email *

Valid email is required

Date of Birth *

Date of birth is required

Gender *

Gender is required

Ethnicity *

Ethnicity is required

Phone Number *

Phone number is required

Preferred method of contact *

Phone Email

Please select a preferred contact method

Suburb *

Suburb is required

City / Town *

City/Town is required

Is there anything else you'd like us to know?

Who is funding this service? *

I (the patient) am paying for it myself ACC Other (e.g. a trust, family member, my employer) Unsure

Please select a funding option

Invoicing Details

First Name *

First name is required

Last Name *

Last name is required

Company (if applicable)

Email *

Valid email is required

Phone Number *

Phone number is required

Billing address *

Address line 1

Address line 1 is required

Address line 2

City

City is required

Post Code

Post code is required

Country

Country is required

PO / Ref for billing (if applicable)

Adult ADHD Assessment

Is there a risk of harming yourself, harming others, or being harmed? *

Yes No

Please answer this question

Preferred time of day for an appointment? *

Morning Afternoon Evening

Please select at least one time preference

Preferred day for an appointment? *

Monday Tuesday Wednesday Thursday Friday

Please select at least one day preference

Preferred appointment type? *

Video / Online In Person (Takapuna, Auckland only)

Please select an appointment type

Booking type? *

Initial Screening 3-Hour Comprehensive Assessment

Please select a booking type

ADHD Symptom Questions *

Please answer Yes or No to the following:

I often fail to give close attention to details or makes careless mistakes in work or other activities.

Yes No

Please answer this question

I often have difficulty sustaining attention in tasks or am forgetful in daily activities.

Yes No

Please answer this question

I often do not follow through on instructions and fail to finish or organise tasks or activities.

Yes No

Please answer this question

I am often easily distracted by extraneous stimuli.

Yes No

Please answer this question

I am often "on the go", acting as if "driven by a motor".

Yes No

Please answer this question

I often talk excessively and can interrupt others.

Yes No

Please answer this question

Do these symptoms significantly impair your functioning (e.g. at home, or work)?

Yes No

Please answer this question

Headache Clinic

Preferred day for an appointment? *

Monday Tuesday Wednesday Thursday Friday

Please select at least one day preference

Preferred time of day for an appointment? *

Morning Afternoon

Please select at least one time preference

We have experts across the country, select your closest clinic *

Please select a clinic

Acute Concussion Clinic

Preferred day for an appointment? *

Monday Tuesday Wednesday Thursday Friday

Please select at least one day preference

Preferred time of day for an appointment? *

Morning Afternoon

Please select at least one time preference

Pelvic Health Appointment

We have experts across the country, select your closest clinic *

Please select a clinic

Is this an initial or follow-up appointment? *

Initial Follow-up

Please select an appointment type

Preferred day for an appointment? *

Monday Tuesday Wednesday Thursday Friday

Please select at least one day preference

Preferred time of day for an appointment? *

Morning Afternoon

Please select at least one time preference

Psychology Appointment

If you are in crisis or require urgent mental health support, please call Lifeline on 0800 54 33 54 or call 111 for immediate assistance.

Do you currently have suicidal thoughts or thoughts about harm to self or others? *

Yes No

Please answer this question

Have you hurt yourself or attempted suicide in the past? *

Yes No

Please answer this question

Preferred day for an appointment? *

Monday Tuesday Wednesday Thursday Friday

Please select at least one day preference

Preferred time of day for an appointment? *

Morning Afternoon

Please select at least one time preference

Please specify any medications you are taking and for what reason. This can be prescribed or non-prescribed. *

Please provide medication information (enter "None" if not applicable)

What would you like help with? *

Anxiety / Depression Stress / Resilience Grief / Loss Chronic Pain or Health Condition

Please select at least one option

Do you consume alcohol? *

Yes No

Please answer this question

If yes, please specify quantity and frequency *

Please specify quantity and frequency

Do you use recreational drugs? *

Yes No

Please answer this question

Psychology Appointment - Continued

What brings you to psychological support at this time? Is there something specific, such as a particular event? *

Please provide some information about what brings you to support

What are you hoping to find from this support? (Goals) *

Please share your goals for this support

VALD Performance Session

We have experts across the country, select your closest clinic *

Please select a clinic

Is this an initial or a follow-up appointment? *

Initial Follow-up

Please select an appointment type

Preferred day for an appointment? *

Monday Tuesday Wednesday Thursday Friday

Please select at least one day preference

Preferred time of day for an appointment? *

Morning Afternoon

Please select at least one time preference

Review & Submit

Thank you for completing the booking form. Please review your details before submitting. A member of our team will be in touch shortly to confirm your appointment.

Contact us by phone

Individuals

Call us or contact your local clinic

North Island:
0800 557 556

South Island:
0800 800 288

Workplace

Talk to us about workplace health services

Occupational health and injury management:
0508 654 325

EAP counselling:
0800 327 669

Accessibility & support

If you require support accessing our services or need help completing the form, please call us - our team will be happy to assist.