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Referral Form
Te Kākano Hauora Referral
Kia ora! What would you like to do?
*
Refer myself
Refer whānau / a friend
Make an agency / professional referral
I would prefer to be seen:
On site - in an allocated therapy space
Out in the community - settings and venues to be discussed with support worker
At home
No preference
Referrer Details
First name
Surname
Relationship to client
Agency name
Agency address
Phone
Email
Client Details
First name
Surname
Date of birth
*
required
Address
Phone
Secondary phone
Email
NHI number
Ethnicity
Iwi affiliation (if applicable)
Gender
*
Male
Female
Other
Referral Information
If you are referring someone else, is the person aware of this referral?
Yes
No
Mental Health Diagnosis
Co-existing conditions (if any)
Support required:
*
Required
Managing medication routines
Budgeting and managing household financial situations
Support to develop home management skills and activities of daily living
Socialization and connecting with natural community supports
Relationship management with children, family, friends, workmates, employers
Assistance to translate therapeutic clinical work into daily life (in vivo support)
Issues with housing, employment, volunteering, activities external to home
Other
Please describe the reason for this referral (include any other agencies involved, safety concerns, AOD history, relevant personal/family history, treatment history, medication, and any other key information).
Upload any relevant documentation (including treatment/discharge summary).
Upload File
Upload supported file (Max 15MB)
Preference for:
Male worker
Female worker
Don't mind
GP Details
Enrolled with GP?
*
Yes
No
Not sure
GP name
Practice name
Address
Phone
Email
Emergency Contact Details
Do you have an Emergency Contact
*
Yes
No
First name
Surname
Relationship to client
Address
Phone
Email
Te Hā Waitaha
Smokefree status:
Smokefree
Not smokefree - Please refer for smokefree support.
Not smokefree - Not interested in smokefree support right now.
Not sure / Prefer not to say
If interested in smokefree support, are you pregnant?
Yes
No
Not sure
Not applicable
If interested in smokefree support, when is the best time to contact you?
Consent
I give my consent for a representative of Purapura Whetu Trust to consult with or request information of a personal nature from any person, or agency as required.
Photography & Video: I understand and agree that any photographs, videos or other images taken of participants during activities associated with Purapura Whetū may be used for promotional purposes of similar activities, including material on websites, social media, and other advertising.
Submit
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