Ka Pou Whenua Referrals Where are you basedCanterburyWest CoastI am making a:Professional ReferralSelf-ReferralHow did you hear about Purapura Whetū?(Required)Social MediaFriend or Whanau MemberProfessional - Social workers, youth workers, NGPBillboard AdvertisingWord of MouthOtherIf other, please provide details(Required)Important:(Required) This referral has been accepted over the phone by a Purapura Whetu Clinician or Kaimahi. This online referral form should only be completed if a phone call has been made to Ka Pou Whenua and accepted over the phone first.Who did you speak to in the above phone call?(Required)Referrer DetailsFull name(Required)Organisation(Required)Te Whatu Ora Specialist Mental Health ServicesPoliceWhakarongorauGP servicesNGO/PHOPurapura Whetu TrustOtherPhone(Required) CR ACNM - 021 598 602 Other Phone(Required)Referrer Email(Required) CDHB-mhcr@cdhb.health.nz Other Email(Required) Tangata Whaiora DetailsInformed consent(Required) The tangata whaiora has given informed consent for the referrer to share relevant information with Ka Pou Whenua. Information: I agree that my information may be shared with other staff of Purapura Whetū for the purposes of my participation in Ka Pou Whenua. Full name(Required)Date of birth(Required) Gender(Required) Male Female Non-Binary Address(Required)Tangata Whaiora emailPhone(Required)Text message okay?(Required) Yes No NHI(Required)Ethnicity(Required)IwiHapuLanguage(s)My DetailsInformed consent(Required) I have given informed consent to share relevant information with Ka Pou Whenua. Information: I agree that my information may be shared with other staff of Purapura Whetū for the purposes of my participation in Ka Pou Whenua. Full name(Required)Date of birth(Required) Gender(Required) Male Female Non-Binary Address(Required)EmailPhone(Required)Text message okay?(Required) Yes No NHIEthnicity(Required)IwiHapuLanguage(s)Next of kin / Contact Person / PeopleClick + to add another person(Required)Full nameRelationshipPhoneEmail Add RemoveReferral DetailsName of GP, Medical Centre and PhoneCurrent Situation(Required)What is happening for me right now?(Required)Briefly describe your current mental health experience or psychosocial challenges.Briefly describe the persons current mental health experience or psychosocial challenges.Do you have a current or historical mental health diagnosis?NoYesDoes the person have a current or historical mental health diagnosis?NoYesPlease list all current and/or historical mental health diagnosisDo you experience issues with gambling? Briefly state any issues you're currently facingBriefly state current substance useIs there an immediate suicide risk?Are any other services currently involved with helping you?NoYesAre there other services currently involved with this person?NoYesWhat Services are currently helping you?What Services are currently involved with this whaiora?Do you have a current safety plan?YesNoDoes the Whaiora have a current safety plan?YesNoAdditional Comments/Notes.Upload safety plans or other relevant information here: Drop files here or Select files Max. file size: 256 MB.
