Referral Form | Te Kākano Hauora

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Referral Form

Te Kākano Hauora Referral

If you would like to make a referral for Te Oranga Activities, please click here.

Kia ora! What would you like to do? *

Refer myself

Refer whānau / a friend

Make an agency / professional referral

Referrer Details

First name

Surname

Relationship to client

Agency name

Agency address

Phone

Client Details

First name

Surname

Date of birth

Address

Phone

Secondary phone

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

Mental Health Diagnosis

Co-existing conditions (if any)

Support 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

Not sure

GP name

Practice name

Address

Phone

Emergency Contact Details

Do you have an Emergency Contact *

Yes

First name

Surname

Relationship to client

Address

Phone

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

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.

Thanks for submitting!

Te Kākano Hauora is provided by Purapura Whetu Trust.

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