I am requesting your services for someone else Eligibility* I have read the eligibility requirementsWho makes the request?Name First Last Organisation (if applicable) Relationship to person being referred* Address* Street Address City ZIP / Postal Code PhoneLandlinePhoneMobileEmail Do you have the consent of the person being referred (or their representative) to provide this information?* Yes No Why not? Details of person being referredName* First Last NHI Number Date of Birth* MM slash DD slash YYYY Gender* Ethnicity* Address* Street Address City ZIP / Postal Code PhoneLandlinePhoneMobileEmail Is there a parent/caregiver/representative we should contact first?* Yes No Name First Last Email PhoneRelationship to person being referred Reason for referral*Other agencies/professionals involvedAre you this person’s clinical key worker (e.g. mental health clinician, paediatrician)?* Yes No Questions for Clinical Key WorkerClinical key worker name Organisation PhoneEmail Patient name Diagnosis By whom When For adults (18 years +) MHA status – Voluntary or MHA Section Please describe how the diagnosis impacts on the person’s independent functioning and participation in everyday activities.Please provide a brief outline of the treatment currently in place.Are there risks of harm to self or others?* Yes No Please provide brief outline or risk Is this person on the Southern DHB risk management system?* Yes No Please provide risk worksheet – upload hereMax. file size: 128 MB.Questions about Clinical Key WorkerPlease provide details of clinical key worker below so we can contact them for details of diagnosis and treatment. Please confirm the person you are referring authorises Synergy Wellness to contact their clinical key worker.Name of clinical key worker Organisation PhoneEmail Consent* Please confirm the person you are referring authorises Synergy Wellness to contact their clinical key worker
