Vaka Atafaga Pacific Nursing Service
6 Hagley St, Porirua City Centre 5022. Phone: 04 832 4661 or 021459 651
Online Client Referral Form
(All fields marked with an asterisk * are required)
Date of Referral
*
-
Day
-
Month
Year
Name
*
First Name
Last Name
Title you would like us to use
*
Miss
Mr.
Mrs.
Ms.
Dr.
Only use my name (No Title)
Not listed (please specify) _________
Date of Birth
*
-
Day
-
Month
Year
NHI Number (Hospital Number if known)
Gender
*
Male
Female
Prefer not to answer
Other (please Specify)_________
Relationship status(check all that apply)
*
Single
Married
In relationship(s) but not married
Separated
Divorced
Widowed
Not listed (please specify)______
What is your clients home/living situation? (tick all that apply)
Live with family
Live with partner
Unstable housing/homeless
Live with flatmates (s)
Live alone
Other living situation (please specify):__________________
Full Address
*
Unit/Flat/Apartment
Street Address
Suburb
City
Post Code
Mobile Number
-
Area Code
Phone Number
(Other) phone number e.g. landline or work mobile
-
Area Code
Phone Number
Is it ok to leave messages if client is unavailable?
*
Yes
No
Email address
example@example.com
Key household contact person details: (if different from the client)
Reason for referral (please specify)
*
Has this referral been sent to other agencies if so please state:
*
Other agencies/workers involved with client's care: e.g. GP, CYF, WINZ
*
Ethnicity
Please select which ethnicity you belong to (you can choose more than one)
*
Cook Island Māori
European
Fiji
Kiribati
Māori
Iwi
Niue
Papua New Guinea
Rotuma
Samoa
Solomon Islands
Tonga
Tokelau
Tuvalu
Not listed (please specify)_________
Interpreter required
*
Yes
No
If 'yes', which Language?
Referral Consent
Please note that Vaka Atafaga Pacific Nursing Service will not accept referrals unless the client or their next of kin/guardian has given consent for the referral to be sent. We will return any referrals if a section has not been completed.
Has the client (or parent/caregiver/legal guardian' of a child) consented to the referral? NOTE: If the client has not consented we cannot process the referral until consent is given.
*
Yes
No
Does the client understand the reason for being referred. If no what is the reason for this.
*
Are there children in the household?
*
Yes
No
If 'Yes' how many and their ages?
Are family members aware of this referral?
*
Yes
No
Any Safety Concerns or risks.
Any relevant safety concerns/risks/ for staff to be aware of for example dogs on property, violence. If this section is not filled in or is filled in with DONT KNOW or NOT KNOWN the referral will be returned as declined.
*
Referrer Details
Is this a self-referral
*
Yes (if yes, you will not need to complete the remainder of the form)
No (if no, continue and complete the rest of the form fully)
Referral completed by
*
First Name
Last Name
Designation for example RN, GP, School Teacher, Social Worker, Family member or Organisation
*
Email Address
*
example@example.com
Work Phone Number
*
-
Area Code
Phone Number
Mobile or landline number (if a family member)
*
-
Area Code
Phone Number
Please select level of priority / urgency for client to be contacted
*
Low
High
Medium
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