Make an agency/professional referral

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Te Waharoa Referral Form

Referral by agency/professional

Consent

The person I am referring has agreed to this referral being made.

Referrer's Details

Referrer's name

Relationship to person being referred

Referral agency (if applicable)

Referrer's email

Referrer's phone

Clients Details

First name

Last name

Date of birth

Ethnicity and iwi (if applicable)

Preferred pronouns:

She/Her

He/His

They/Their

Other

Address

Phone

NHI (if known)

GP / Medical Centre

Emergency Contact

Emergency contact name

Relationship to person being referred

Emergency contact phone

Referral details

Which Te Waharoa service(s) or programme(s) is the client interested in?

Current support/interventions needed:

Existing supports/interventions (including any other services/professionals involved):

Previous supports/interventions (including any other services/professionals involved):

Any other relevant information:

The client is...

Smokefree

Not smokefree and is interested in support to become smokefree

Not smokefree and is not interested in support to become smokefree

(Smokefree status unknown)

Consent

Information: I agree that my information may be shared with other staff of Purapura Whetu for the purposes of my participation in Te Waharoa activities.

Photography & Video: I understand and agree that any photographs, videos or other images taken of participants during activities associated with Purapura Whetu may be used for promotional purposes of similar activities, including material on websites, social media, and other advertising.

Office Hours

Mon-Fri: 8:30AM - 4:30PM

Purapura Whetu Trust

166 St Asaph Street

Christchurch 8011

tewaharoa@pw.maori.nz
0800 4 WHETU

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