Oranga Day Activities Referral Form

Referral Type*

Self referral
Referral from Support Worker
Referral from Whanau/Family member
Referral from Agency/Professional

Please note all referrals must have a support worker

Client Information

Date of Referral*

Client Name*

First Middle Last

Date of Birth*

Address*

Street Address City

NHI

Ethnicity

Phone*

Iwi

Mental Health Diagnosis (Compulsory)*

Physical Health Diagnosis

GP name and contact number:*

Te Oranga Activities

Please tick which programme your client would like to attend: (Please be aware that some programme numbers are limited)

Programmes:

Raranga - Weaving
Mahi Tuinga - Sewing
Toirau – Mixed Media Art
Ihi – Singing & Te Reo Māori
Te Hauora Mai - Healthy Me
Toi Whakairo – Carving
Toi Ataata - Pastel Art
Te Waonui & Adventure Therapy
Taiora - Swimming (QEII)

Are there any specific needs/requirements/triggers or risk issues that program staff need to be aware of? *Please attach a safety plan if necessary

Any Concerns?

Safety Plan or other documents to upload

Max. file size: 256 MB.

Te Hā Waitaha

Are you and your whānau smoke free?

Are you (or your whānau) interested in support from us to become smoke free?

Is the client/whānau smoke free?

Is the client/whānau interested in support from us to become smoke free?

To help us improve our service, can you please tell us more about why you said "No"?

Support Worker Information

Please be aware that referrals without a support worker will not be accepted

Support Worker Name (required)*

First Last

Organisation*

Organisation (other)

Support Worker Phone*

Support Worker Email

Emergency Contact

Emergency Contact Name*

First Last

Relationship*

Emergency Contact Phone*

Referrer Information

Referrers Name

Referrers Contact Phone

Referrers Email

Agency / Relationship to client

Te Oranga Activities Referral Form