Request a stay or support service

This form is for existing Hummingbird House clients who have previously been referred and accepted for services.

If this does not apply to you, please visit our Contact us page for information about getting in touch.

Have you previously been referred to and accepted for services at Hummingbird House? (required)

If you are interested in accessing Hummingbird House services, please speak with your treating clinical team about a referral. Once we receive the referral, we can explore how Hummingbird House may be able to support you. If you would like any further information please contact the team.

What service are you interested in? (required)

Child’s full name (required)

Name of person completing the form or referrer (required)

Are you the parent or legal guardian? (required)

Do you have parental or legal guardianship consent? (required)

Phone number (required)

Email address (required)

Preferred dates for respite (required)

E.g. 10-15 July, 20-22 August

Any additional information (optional)