Referral Form

REFERRER DETAILS

Name of Referrer (required)

Referrer's Email Address

Date

Agency

Job Title

Address

Telephone Number

Facsimile Number

CLIENT DETAILS

Name of Client

NHI Number (required)

Date of Birth (required)

Gender
 Male Female

Address

Cellphone Number

Email

Is client aware of and in agreement with referral?
Yes No 

Number of family members living under the same roof as client

If known, please list all household members of the client, including their full name, age, gender and relationship to the client

Please list all other relatives living in New Zealand

General Practitioner and Address

Employment?
Yes No 

Days and Hours of Work (if applicable)

Attending English Language Classes?
 Yes No

Day(s) and Time of English Language Classes

School/Early Childhood Centre (if applicable)

Other study/training being undertaken

Summary of Issues (Please include a brief outline of referrer's concerns, acknowledgement of the client's torture/trauma history and any other serious health concerns that could have a direct impact on their mental health e.g. living with a serious chronic condition)

Current Medications

CULTURAL INFORMATION

Country of Origin

Language(s) Spoken

Interpreter Required
Yes No 

Preferred Language for Interpreting

Gender Preference of Interpreter
Male Female 

Gender Preference of Counsellor
 Male Female

Client's support person in New Zealand

Do you have a copy of the RAS Referral Summary?
 Yes No

If you have a copy of the RAS Referral Summary PLEASE SEND US A COPY AS SOON AS YOU HAVE SENT THIS REFERRAL - Thank-you

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If you would like a copy of this referral for your records, CLICK ON THE PRINTER ICON BELOW BEFORE SENDING