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Agency Referral
Agency Referral Form
Client Details:
Name
(Required)
First Name
Last Name
Address
City/Town
Ethnicity
Maori
Pacific Islander
NZ European
Other
NZ Resident?
Yes
No
Phone 1
Phone 2
Email
Todays Date
MM slash DD slash YYYY
Age
Date of Birth
MM slash DD slash YYYY
Gender/pronoun
NHI No
Referrer Details and Client Health Information:
Name
(Required)
First Name
Last Name
Service/Organisation
Relationship/Role with Client
Phone 1
Phone 2
Email
Presenting Problem/Reason for Referral
(Please include alcohol and other drug use)
Relevant History
(Previous contact with Addiction/Mental Health Services, other background information)
Physical/Mental Health conditions
Safety/Risk Issues
(harm to self/others etc)
Name of GP and Medical Centre
Contact Number
Legal Issues
Name of Probation Officer
Contact Number
Please list and provide contact details of other services/professionals involved in this persons care:
Name
Role/Service
Phone
Add
Remove
Client consent obtained for Get Smart & these services to share their relevant health information?
Yes
No
Other Information
Ability to speak & understand English
Yes
No
Preference of Counsellor
No Preference
Male
Female
Any Mobility/Literacy Issues/Special Needs
Gambling Issues
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