* Today's Date - (dd/mm/yyyy)
* Client Name
* Client Gender
* Client Address Line 1
Client Suburb
Client Town
* Client Phone Number
* Client Date of Birth - (dd/mm/yyyy)
* Client Ethnicity
* Client Language
Does the Client need an interpreter Yes
* Time in New Zealand
* Name of Client Medical Practice and/or Name of GP
Client NHI Number (If Known)
* Referred By
Service
* Referrer Address Line 1
Referrer Suburb
Referrer Town
* Referrer Phone
* Referrer E-mail Address
* Reason for Client Referral? (max 1000 characters)
Kessler Scale ( if known)
Risk / Safety ( max 100 characters each )
Family Violence - Reason:
Mental Health - Reason:
Other - Reason:
* Name of Client Emergency Contact
* Phone Number of Client Emergency Contact
Is this referral urgent? Yes
Do you have the client's consent to refer? Yes
