Referral Form
First Name:
*
Surname:
*
NHI Number:
*
Gender:
*
Please select gender
Male
Female
Date of Birth:
*
Day
1
2
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5
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31
Month
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12
Phone Number:
*
Address1: Street:
*
Address2: Suburb/Area:
Address3: City:
Ethnicity:
Please select ethnicity
Afghani
Bangladeshi
Bengali
Bhutan
Brunei
Burmese
Cambodian
Cambodian Chinese
Chinese
East Timor
East Timor Chinese
Filippino
Filippino Chinese
Gujarati
Hong Kong Chinese
Indian
Indo-Fijian
Indonesian
Indonesian Chinese
Iran
Japanese
Javanese
Korean
Laotian
Macau Chinese
Malay
Malaysian Chinese
Maldives
Mongolia
Nepalese
Other Asian
Other Northern Asian
Other Western Asian
Pakistani
Punjabi
Singaporean
Singaporean Chinese
Sri Lankan
Taiwanese
Tamil
Thai
Thai Chinese
Tibetan
Vitenamese
Vitenamese Chinese
Language:
(Please use "Ctrl" key to select the multiple languages)
Please select language type
Burmese
Cambodian
Cantonese
Chiu Chow
English
Fijian (Hindi)
Filipino
Foochow
Fu-Chan
Gujarati
Hakka
Hindi
Hokkien
Indonesian
Japanese
Khmer
Korean
Lao
Malay
Mandarin
Pakistani
Pampango (Filipino)
Punjabi
Shanghainese
Sign Language
Sinhalese (Sri Lankan)
Sri Lankan
Tagalog (Filipino)
Taiwanese
Tamil
Telugu
Teochew (Chaozhou language)
Thai
Tibetan (Xizang)
Vietnamese
Family/Contact Person with Phone Number:
Clinical Service
:
Clinical Key-Worker:
English level?
1
2
3
4
5
1 = Non-English, 2 = Limited English, 3 = Good, 4 = Very good, 5 = Excellent.
Interpreter required?
Current Medication:
Current Diagnosis:
Any alcohol & drug issues?
Yes
No
Now
Past
Sometimes
Client has dependent children including grandchildren?
*
Yes
No
Number of Children
Ages of Children
(Please use "Ctrl" key to select the multiple ages)
Please select the age of each child
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Employment Status
*
Please select employment
Full-time
Other
Part-time
Retired
Student
Unemployed
Risk & Safety Concerns (including risk to property):
(Are there or have there been any concerns?)
Referrer Type:
Please select
Asian Health
Media
Promotion
Re-referred
WATIS
Word of Mouth
Referral Purpose and Desired Outcome(s):
Name of Referring Agency:
*
Please select
Adult-EPI
Adult-He Puna Waiora-IPU
Adult-Liaison Psychiatry
Adult-Maternal Mental Health
Adult-MHC North 1
Adult-MHC North 1 Crisis Team
Adult-MHC North 2
Adult-MHC North 2 Crisis Team
Adult-MHC Rodney
Adult-MHC West 1
Adult-MHC West 1 Crisis Team
Adult-MHC West 2
Adult-MHC West 2 Crisis Team
Adult-Rodney Crisis Team
Adult-Waiatarau
Child and Youth-Liaison Psychiatry
Child and Youth-Marinoto Child North
Child and Youth-Marinoto Child West
Child and Youth-Marinoto Youth North
Child and Youth-Marinoto Youth West
Community Agencies
GP
Mason Clinic
MHSOA-Liaison Psychiatry
MHSOA-North
MHSOA-Rodney
MHSOA-Ward 12
MHSOA-West
NS-Inpatient Wards
Private Psychiatrist
Self
West-Inpatient wards
Name of Person Referring:
*
Contact Phone Number:
*
Email Address:
*
Referral Date:
*