TE ORA PUAWAI REFERRAL INBOUND FORM

MAIA SERVICE REFERRAL FORM

For Māia, service and other support queries
WELCOME

You are making a referral to the Te Ora Puāwai Māia Navigation service.

If you have any queries before you complete this form, please email us at customerquery@teorapuawai.nz and one of our staff will get back to you within 48 hours of receiving this referral.

Māia: Is a free service for people who have:
- Two or more Long Term Health Conditions
- And or a Disability
REFERRER DETAILS

Please complete your details below
Organization Name*
Type Nil if not an org
Name of Main Contact/Referrer*

First NameLast Name
Phone Number of Main Contact/Referrer*

Area CodePhone Number
Email of Main Contact/Referrer*
example@example.com
Is this your first time referring to Te Ora Puawai?*

YesNo
How did you hear about Te Ora Puawai?*

Word of MouthSocial MediaNetworkingPresentationOther

CUSTOMER BASIC MEDICAL INFO
Name of GP Service
GP Doctor NAME

First NameLast Name
NHI Number*
Put Unknown if you don't have this
Does your referral have any support people? Please name them if you can?*
Type nil if unknown
CRITERIA - Medical alerts. Please state at least 2 long-term health conditions e.g. Diabetes, Cancer etc. and /or any disabilities
Condition 1*
Condition 2*
Condition 3
Condition 4

Referral information

Tell us what you would like us to focus on with your referral
What is the nature of your referral?*
Support for Long Term Health Conditions, Waiora Wellness Centre, Other support
What would you like the Whanau Navigator to focus on with your person?*
Type nil or unsure if unknown
Does the customer give consent for us to contact them regarding your referral*

YesNo
SOCIAL ALERTS – Are there any safety issues that we should know about that would affect our engagement with this customer.*
Type Nil if no issues or alerts
Should be Empty:

MAIA SERVICE REFERRAL FORM