REFERRAL FORM

GRACE FOUNDATION Rehabilitation & Reintegration Referral Form

He Tangata
Full Name*

First NameMiddle NameLast Name
Birth Date*

DayMonthYear
Marital Status*

MarriedDefactoSingle
Number Of Dependants*
Gender*

malefemale
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity*
Hapu
Iwi
WINZ Client Number (if known)
PRN (Corrections/Police)*
NHI (number)
Next Of Kin
Full Name

First NameLast Name
Address

Street Address

City

Postal / Zip CodeCountry
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Email
example@example.com
Prison Case Manager and or Probation Officer
Name

First NameLast Name
Prison Address and or Probation Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
E-mail
Lawyer and or Layman / Advocate
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Email
example@example.com
Referrals' Details / History
Reason For Referral*
Current Convictions
Total Prison Sentence
Time Served To Date*
Sentence End Date

DayMonthYear
Parole Hearing Date
Number Parole Hearing

1st2nd3rd4th5th6th7thOther
Time In Remand
Addictions
Drug &Alcohol. (please tick applicable box)

MethSyntheticsMarijuanaUnprescribed medsSpirits (Alcohol)Beer (Alcohol)CigarettesGambling
Other
Education
Highest level of education
List Trades/certificates gained
Risks/Concerns/Needs
Safety and Risk Issues
Gang Affiliations (Grace Foundation Take Gang Members)
Mental/Physical Health Concerns
Responsible Clinician & Contact Details
Doctor & Contact Details
Medication
Present Situation / Other Comments
Grace Foundation Provide
1. Furnished room;     bed, tallboy, side drawer.

2. Food supplies;        cereals, meat, day class shared lunch.

3. Transport:               Winz, doctor, probation, class, church, programs, excursions

4. Day Class:               'Soulutionz' 3 Phase Program/Activities

Phase 1: 12 weeks

Phase 2: 12 weeks

Phase 3: 12 weeks
Accommodation/Rehabilitation/Re-integration Costs
Total Admission costs for accommodation and wrap around services:

Grace Foundation Auckland (Mens):

Bond:                         $400.00 (1 weeks rent.)

Linen Kit: $100.00 (Grant)

Advance:                   $800.00 (2 weeks rent).

Rent per week:           $400.00

TOTAL:                     $1,300.00  (Total Admission Costs)

Grace Foundation Auckland (Women):

Bond:                        $530.00, (1 weeks rent + linen grant)

Advance: $860.00 (2 weeks rent)

Rent per week:           $430.00.

TOTAL:                      $1,390.00 (Total Admission Costs)

Note:   Total admission costs will be covered by 'Work & Income NZ' (WINZ)
Grace Foundation Charitable Trust (Auckland)
Free Call Number: 0508 447 223 (0508 4GRACE)
Email: admin@gracefoundation.co.nz
Date Referral Form Completed

DayMonthYearHourMinutesAM/PM Option
Should be Empty:

GRACE FOUNDATION Rehabilitation & Reintegration Referral Form

Next Of Kin

Prison Case Manager and or Probation Officer

Lawyer and or Layman / Advocate

Referrals' Details / History

Addictions

Education

Risks/Concerns/Needs

Grace Foundation Provide

Accommodation/Rehabilitation/Re-integration Costs

Grace Foundation Charitable Trust (Auckland)

Free Call Number: 0508 447 223 (0508 4GRACE)

Email: admin@gracefoundation.co.nz