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?*YesNoWhy not?Details of person being referredName* First Last NHI NumberDate of Birth* Date Format: 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?*YesNoName First Last Email PhoneRelationship to person being referredReason for referral*Are you this person’s clinical key worker (e.g. mental health clinician, paediatrician, GP)?*YesNoQuestions for Clinical Key WorkerClinical key worker nameOrganisationPhoneEmail Patient nameDiagnosisBy whomWhenFor adults (18 years +) MHA status – Voluntary or MHA SectionPlease 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?*YesNoPlease provide brief outline or riskIs this person on the Southern DHB risk management system?*YesNoPlease provide risk worksheet – upload hereQuestions 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 workerOrganisationPhoneEmail Consent* Please confirm the person you are referring authorises Synergy Wellness to contact their clinical key worker