Whānau Ora Navigator Referral Form Step 1 of 3 33% Referral type* Agency/Professional Self Whānau member Referrer's Details - Agency/ProfessionalReferrer's Name* First Last Agency Name* Agency Address Street Address Address Line 2 ZIP / Postal Code Referrer's Phone*Referrer's Email* Referrer's Details - Whānau memberThis section is about you - the whānau member making the referral, not the client.My name* First Last My relationship to the client* My address Street Address Address Line 2 City ZIP / Postal Code My phone*My email Client DetailsClient Name* First Last Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City ZIP / Postal Code Phone*Second phoneEmail Ethnicity* NZ Māori NZ European Samoan Tongan Pacific Island Chinese Indian Other (please specify below) Unknown Ethnicity:* Iwi Secondary Iwi Gender* Male Female Other NHI number* NHI number* Enrolled with GP?*YesNoUnknownGP DetailsGP Name Practice Name Address Street Address Address Line 2 City ZIP / Postal Code PhoneEmail Alternate/Emergency Contact DetailsName First Last Relationship to client Address Street Address Address Line 2 City ZIP / Postal Code Phone Referral DetailsReason for the referral:* Housing - *Please note: We are not a housing provider. We can assist with pathways to finding housing. Financial Connection with whānau Connection with community Counselling - *Please note: This service does not provide counselling. We can assist with pathways to receiving counselling. Grief support Building self-confidence Other (Eg: support getting drivers license, support with adult education) Please select any that apply.Other: Please use this space to provide reason for referral*Please provide any extra information that may be helpful for our Whānau Ora Navigator to know:Upload any relevant documentation: Drop files here or Select files Max. file size: 256 MB. Te Hā WaitahaAre you and your whānau smoke free?Please selectYesNoAre you (or your whānau) interested in support from us to become smoke free?Please selectYes - I would like to be contacted by a Stop Smoking Practitioner.NoWhen is the best time to call you?* Are you pregnant?YesNoThird ChoiceTo help us improve our service, can you tell us more about why you have selected 'No'?Is the client smoke free?Please selectYesNoUnsureIs the client interested in support from us to become smoke free?Please selectYes - They would like to be contacted by a Stop Smoking Practitioner.NoUnsure - They may like to be contacted by a Stop Smoking Practitioner.When is the best time to call the client/whānau?* Is the client/whānau pregnant?YesNoUnsureTo help us improve our service, can you please tell us more about why you said "No"?ConsentIs the client aware of this referral?*YesNoConsent for release of information I give my consent for a representative of Purapura Whetu Trust to consult with or request information of a personal nature from any person, or agency as required.CAPTCHA
