Poutiri Trust Referral Form

All new referrals will be considered at our weekly MDT held every Monday morning.

Date of Referral*

Date

NHI Number ( if known)

Client's Name*

First NameFamily Name

Date of Birth*

Date

NZ Citizen/Resident/CSC?*

YesNo

Address*

Main Phone*

Alternative Phone

Gender*

MaleFemaleOther

Interpreter needed?*

YesNo

If YES, what language?

(Phone or Email)

Ethnicity Details - Tick the options which apply to you.*

MāoriNew Zealand EuropeanPacific IslandOther

Iwi / Hapū ( if known)

Reason for referral: (Please complete further information on page 2)*

NEXT OF KIN / EMERGENCY CONTACT: (please provide the following information if known):
NB: This section must be completed for all clients under 16 years of age

Next of Kin Name

First NameLast Name

NEXT OF KIN - Relationship to you

Next of Kin Phone

Please enter a valid phone number.

Alternative contact details:

REFERRER DETAILS (Please tick relevant boxes ✓ )

Referral Type:*

SelfWhānauExternalInternal

Referrer Name*

First NameLast Name

Organisation*

Relationship*

Referrer Email*

Referrer Work Phone*

Please enter a valid phone number.

Referrer Alternative Phone*

Please enter a valid phone number.

BELOW HERE FOR OFFICE USE ONLY
FOR COMPLETION BY POUTIRI KAIMAHI:

Sent to intake

YES

Initial

Date

Entered to CMS

YES

Initial

Date

INTAKE - Referral Accepted

YESNo

Designated Key Worker:

Comments/Reason for Decline:

RP Updated

YES

Initial

Date

Accepted to:*

Completed referral uploaded to file

YES

Initial

Date

Please complete further information on page 2

Please complete the following details