Asian Mental Health Client Service

	Asian Mental Health Cultural Support Coordination Services
	Phone: (09) 486 8920 ext 3042 Fax: (09) 486 8347

Referral Form

First Name: *
Surname: *
NHI Number:*
Gender:*
Date of Birth:*
Phone Number: *
Address1: Street: *
Address2: Suburb/Area:
Address3: City:
Ethnicity:
Family/Contact Person with Phone Number:
Clinical Service:
Clinical Key-Worker:
English level?	1 2 3 4 5
Interpreter required?
Current Medication:
Current Diagnosis:
Any alcohol & drug issues?	Yes No Now Past Sometimes

Risk & Safety Concerns (including risk to property): (Are there or have there been any concerns?)
Referrer Type:
Referral Purpose and Desired Outcome(s):
Name of Referring Agency:*
Name of Person Referring:*
Contact Phone Number:*
Email Address:*
Referral Date:*