Companion Walking Service Referral Form

Use this form to make a referral to the Companion Walking Service for Wellington City and Porirua. Once submitted, a Service Coordinator will be in touch with you.

Please note, we are not currently taking referrals for the Hutt Valley due to a staff shortage.

CWS Referral Form

Before filling in this form, please check and mark the following:

Declaration:

CLIENT DETAILS

CLIENT SITUATION

Hazards in the home (please select any home hazards for AVS workers):

REFERRER'S DETAILS