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Referral Form

All fields marked with an * must be completed

CLIENT DETAILS

*Referral Date:

*Surname:

*First Name(s):

*Address:

Ethnicity:

Iwi:

GP:

*Date of Birth:

Phone No:

Email:

NHI No:

CSC No:

Expiry Date:

NZ Residency:

Yes No

Gender:

First Language:

Communication Method (Interpreter Required):

If the person has been identified as Maori would they like a culturally appropriate facilitator?

Yes No

Present Living Situation:

Living With:

Risk Factors:

Yes No

If yes, please identify:

Please attach documentation detailing risk and safety concerns and supports that are being utilised to manage these risks.

IMPORTANT: Has the person or guardian you are referring given consent to disclose their information, and are they requesting this service?

Yes No

If consent has not been obtained, give reason:

ALTERNATIVE CONTACT PERSON/NOK DETAILS

Surname

Title

First Name(s)

Address

Relationship

Phone Number

DISABILITY DETAILS

Please attach confirmation of diagnosis from a specialist and any other supporting reports

*Primary:

Secondary:

Reason for Referral:

Urgency of Referral:

Additional Info:

HEALTH INVOLVEMENT DETAILS

Specialist Clinician:

Social Worker:

Therapists:

Agency / Organisation:

ACC:

Psychologist:

Paediatrician:

Other:

HOSPITAL DISCHARGE DETAILS

Proposed Discharge Date:

Short term services in place?

Yes No

Start Date:

End Date:

REFERRER DETAILS

*Name:

Address:

Phone:

Agency:

*Email:

Relationship to Client:

ATTACH SUPPORTING DOCUMENTS

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Kaitohutohu

Referral

Referral Form