Referral Form Please ensure you complete all questions First Name:

Last Name:

Date of Birth:

Gender:

Ethnicity:

Hapu / Iwi Affiliations:

Address: Email: Telephone:

Mobile:

Work and Income #:

Smoker: Y/N

Reason for Referral (Specific needs / goals):

PHYSICAL and MENTAL HEALTH HISTORY

NHI Number:

Diagnosis:

Disability (if any):

PERSON BEING REFERRED PLEASE SIGN: I give informed consent for this referral and to the service to be provided

Signature

Date:

Referred by: (Complete as required)

Name: Relationship/Title/Organisation: Email/Telephone:

How did you hear about us:

We deliver services in: Taranaki and Waikato District Health Board regions and Taupo (refer to our website for more information)

Phone: 0800 77 57 57

Fax: 07 829 4826

Email: [email protected]

Referral Tracking (Progress to Health to complete) Referral Received – staff member: (date)_________________ Referral Received- Admin: (date) ____________________ Recordbase Entry: (date) __________________________

Referrer Advised of Referral Outcome: (date) __________________ by email / telephone (circle one)