I am requesting your services for someone else

Eligibility*

I have read the eligibility requirements

Who makes the request?

Name

First Last

Organisation (if applicable)

Relationship to person being referred*

Address*

Street Address City ZIP / Postal Code

Phone

Landline

Phone

Mobile

Email

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 referred

Name*

First Last

NHI Number

Date of Birth*

Gender*

Ethnicity*

Address*

Street Address City ZIP / Postal Code

Phone

Landline

Phone

Mobile

Email

Is there a parent/caregiver/representative we should contact first?*

Yes
No

Name

First Last

Email

Phone

Relationship to person being referred

Reason for referral*

Are you this person’s clinical key worker (e.g. mental health clinician, paediatrician, GP)?*

Yes
No

Questions for Clinical Key Worker

Clinical key worker name

Organisation

Phone

Email

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 here

Questions about Clinical Key Worker

Please 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

Phone

Email

Consent*

Please confirm the person you are referring authorises Synergy Wellness to contact their clinical key worker