Referral Form | Te Kākano Hauora

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

Gender

Male

Female

Other

If you are referring someone else, is the person aware of this referral?

Yes

No

Preference for:

Male worker

Female worker

Don't mind

Enrolled with GP?

Yes

No

Not sure

Do you have an Emergency Contact

Yes

No

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

Te Kākano Hauora Referral