Referrals Form

Referral Form

Please complete this form to register for Ngā Kākano Family Health Services.
Please Choose TYPE OF REFERRAL*

Self ReferralWhanau ReferralAgency Referral
What services do you wish to enroll in? Please tick as many as you like*

Mental Health ServicesMental Health and Addiction support (Alcohol and Drug Program - Adults)Mental Health and Addiction Counselling (Alcohol and Drug Tamariki/Rangatahi)Tūāpapa Auaha - Healthy Lifestyles for taiohi/rangatahiAsthma and Respiratory ServicesDiabetes servicesKaumatua and Kuia ProgrammeTamariki Ora Well Child ServicesWhānau OraMirimiri Service (Must be an enrolled client of Nga Kakano clinic)Waka TereHIPS (internal purposes only)Tūāpapa Māmā and Pēpi
What kind of Whanau Ora support is required?
Referrer Details
Name of Agency*
e.g. Police
What is your Relationship to the Person being Referred?*
e.g. Brother \ Case Manager
Name of Referrer:*

First NameLast Name
Contact Phone: *

Area CodePhone Number
E-mail
My Details
Whanau Details
Client Details
Are you currently enrolled as a Nga Kakano Patient?*

YesNo
Is Whanau enrolled as a Nga Kakano Patient?

YesNo
Is Client enrolled as a Nga Kakano Patient?

YesNo
Gender*

MaleFemaleGender Diverse
I am 18yrs of age or over?*

YesNo
Whanau is 18yrs of age or over?*

YesNo
Client is 18yrs of age or over?*

YesNo
NHI Number
(IF KNOWN)
Date of Birth

DayMonthYear
Date
Name:*

First NameLast Name
Contact Phone: *

Area CodePhone Number
Email
example@example.com
Address*

Street Address

Suburb

City

Post Code
Ethnicity Details:*

New Zealand EuropeanMāoriSamoanCook Island MāoriTongan Niuean Chinese IndianOther
Primary Language*

EnglishMāoriOther
Emergency Contact Name:
Relationship:
e.g. Guardian
Emergency Contact Phone:

Area CodePhone Number
Medical Details
Medical Centre:
GP Name:
GP Phone:
Please let us know more about your health needs*
e.g. Type NONE if uncertain
Medications - known allergies:

Do you have a Community Services Card?

YesNo
Does Whanau have a Community Services Card?

YesNo
Does Client have a Community Services Card?

YesNo
If yes - Day / Month / Year of Expiry

DayMonthYear
Date
Card Number (if known)
Do you have a High User Health Card?

YesNo
Does Whanau have a High User Health Card?

YesNo
Does Client have a High User Health Card?

YesNo
If yes - Day / Month / Year of Expiry

DayMonthYear
Date
Card Number (if known)
Are You/Whanau or Client employed? (applies to 18 years & over ONLY)*

Yes full-timeYes part-timeYes casualYes self employedNot employed ( tick here if uncertain)
Occupation:
Employer Name:
Employer Address:
Why is this asked for?
If Ngā Kākano has enough patients working for an employer, we will approach them to offer health checks on-site to try and make our services more accessible for you.
Smoking Status (applies to 15yrs & over ONLY)

Never SmokedEx-SmokerCurrent Smoker
Would you like support to quit?

YesNo
Consent to Receive Communications via Email - Text - Patient Portal (if available).
Please UNTICK any of the following that you don’t consent to:*

Text MessageEmailFacebook MessengerPatient Portal
Facebook name (if selected)
Your Rights.
Whanau Rights.
Client Rights.
Note: you can read your rights by clicking here or view video here
Note: you can find more about this here
I am eligible to enroll because:*

I am a New Zealand citizen (If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below) ORI am not a New Zealand citizen but I confirm that I have provided proof of my eligibility
My agreement to the enrolment process*

I understand that by enrolling with Ngā Kākano Family Health Services I will be offered a range of Ngā Kākano Community Health Services and my name, address and other identification details will be shared in order for other relevant Ngā Kākano services to make contact with meI understand my rights when receiving Ngā Kākano Family Health Services and have read or viewed the Code of Health and Disability Services Consumers' Rights.
My declaration of entitlement and eligibility for Ngā Kākano Community Health Services*

I am entitled to enrol because I am residing permanently in New Zealand. The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months
Making a complaint*

I understand and have read what to do if I wish to make a complaint.
Office Use Only
- The following Section is to be printed out by Appointed Service and Signed off by the Client.
- The Completed form to be returned to Referral Team by appointed Service Coordinator.
The Client understands and agrees to the following

I am aware of my Patient rightsI am aware of the complaints processi am aware Nga Kakano undertakes to ensure personal information is not available without your written consent.
Client Signature
Please Sign Here
Date Signed
Please Enter Date Signed

Please Sign Here*
Date Signed

DayMonthYear
Should be Empty:

Rows	NAME OF MEDICATION	DOSE	FREQUENCY
Item 1
Item 2
Item 3
Item 4
Item 5

Rows	Authority (Where signatory is not the enrolling person)
Authority Full Name
Relationship
Contact Number
Basis of Authority (e.g parent of a child under 16 years of age)

Referral Form

Referrer Details

My Details

Whanau Details

Client Details

Medical Details

Your Rights.

Whanau Rights.

Client Rights.