Mental Health Referral

Please be aware that when the form below is submitted electronically, it is not encrypted.

Click here to download a Microsoft Word version to print and Fax to 06-946-9835 OR Please press the 'Email Form' button at the bottom of the page on completion. Note: You can print a copy of this completed page from your screen - remember to print landscape, not portrait mode. Sections in red are mandatory

To: Mental Health Service Access Centre

Referral from:   Date:   Surname:   NHI No:   DOB:   Given names:   Gender: Male Female Age: Other Names:   Occupation/School: Medical alerts: Address:   Home phone: Business phone: Ethnicity:   Years in NZ:     If Maori :- Iwi: Hapu:     Active MHS client Previous client Unknown MH Team: Primary clinician: Psychiatrist/RC: Legal Status - Nil MHA   (specify section)   PPPRAct CYPFA CJAct General Practitioner:   Phone: Fax: Address:         Next of Kin/Guardian/Support person Name: Address: Phone: REASON FOR REFERRAL TO THE ABOVE SERVICE Details: Main mental health/A & D symptom/problems - include behaviour, key event, time of event, circumstances, sequence of events that led to contact/referral. Include family history/cultural/social relationships:   Current Medications: (enter nil if none currently presecribed)   Other Agencies Currently Involved (please list): Possible Disorder/Diagnosis Identified Stressors Mood Disorder Anxiety/Phobia Depression Mania Delirium/Dementia Schizophrenia Psychosis Post Traumatic Stress Attention Deficit/Hyperactivity Alcohol Abuse Substance Abuse Other Primary Support group / family / whanau Social Environment Ante/Post Natal Loss Custody Physical Illness Occupation/School Abuse Housing Legal Financial Other ACTION PLAN Indicate actions taken and plans for management prior to acceptance by MHS:   Describe Outcome desired for this Referral:   Identify any support client requires for assessment eg cultural/interpreter/family: Referrer name and designation:   Referrer email:   Date:   Time:   Contact phone:       1. Referral discussed with:    Client - Yes Yes No    * Whanau/Family/Guardian - Yes No 2. In agreement with:    Referral client - Yes No    * Whanau/Family/Guardian - Yes No * Discussed with Whanau/Family/Guardian with Client consent where necessary Remember to print a copy of your completed form in landscape, not portrait mode