Health Professionals Referral Form

Health Professionals Referral Form

Melanoma New Zealand Counselling Service
Has the individual being referred consented to the referral and to be contacted by the Melanoma NZ Counsellor?

YesNo (Please note that the individual will not be contacted until consent to referral is confirmed).
Referring Clinician*
Your organisation
Your role
Your email*
Your phone*
Patient’s details
Salutation
Patient's full name

First NameLast Name
Birthdate

DayMonthYear
Ethnicity

NZ EuropeanMāoriPacific PeoplesAsianEuropeanMELAA (Middle Eastern/Latin American/African)Other ethnicity
Mobile phone

PREFIXNumber
Email
example@example.com
Address

Street number and name

Suburb

City or regionState / Province

Postcode
GP Name
GP Phone Number

Area CodePhone Number
GP Email
example@example.com
Emergency contact (Please provide two contacts if the patient does not have a current GP):
(Full name, mobile, email)
Melanoma staging
PLEASE SPECIFY:
Medical diagnosis and treatments
Please enter relevant medical detail:
Medications (mental health related only). State ‘none’ if no medication has been prescribed in the past 6-months, or ‘unknown’ if you do not know.
Reasons for referral:

AnxietyStressMood DisturbanceAnxiety + MoodAdjustment/GriefNot SpecifiedOther
Please comment on current issue and reason for referral:
Existing mental health history (if known). Has the patient previously engaged with mental health or psychological services? If so, please outline when and with whom.
Is the patient engaged with mental health or addiction services? If so, please provide details.
Do you have concerns about the patient’s current risk of harm to self/others?

YesNo
If yes, please give detail:
If your patient is experiencing an emergency or crisis, please dial 111 for Emergency Services, or phone NZ DHB Local Mental Health Crisis Teams (CATT Team), or Lifeline on 0800 543 354 (0800 LIFELINE) or free text 4357 (HELP), or NZ Mental Health Support Agencies.

Please note that the MNZ Counselling Service is not an emergency or crisis service.
Family/whānau details
Other people living in the individual’s home (names, ages, gender, relationship).
Interpreter required?

NOYES
Please advise language spoken:
Source Campaign
By submitting this form, you confirm that the individual being referred has permitted you to contact Melanoma New Zealand Counselling Services on their behalf and consented to you providing this personal information to Melanoma New Zealand to establish a counselling appointment for the client.
Should be Empty:

Health Professionals Referral Form

Patient’s details

Medical diagnosis and treatments

Family/whānau details