Referral – Kaupapa Maori Community Support Services KM Community Support Team - Referral for support Request support for:* Community Support - Adult Mental Health Community Support - Tamariki/Rangatahi Mental Health Community Support - Kaupapa Maori (non clinical) Please complete the following information on the person you are referring to our serviceName* First Last Preferred Name* First Gender* Female Male Rather Not Say Current address of the consumer* Street Address Address Line 2 City Contact Number for the consumer* Date of Birth* DD slash MM slash YYYY NHI Number (if known) Marital Status* Iwi Affiliation Religion Smoking status?* Current smoker (has smoked tobacco within the last 30 days) Never smoked tobacco Ex smoker (has no smoked tobacco in the last 30 days) Ethnicity* Current GP* Please enter the tangata whaiora's GP and/or clinic details. If you do not know, please write "unknown".Legal Status* Informal The Mental Health (Compulsory Assessment & Treatment Act 1992) Is the consumer involved in any of the following?* Education Volunteer Work Paid Employment Sorry, don't know Further information to above question.If the consumer is involved in any education course, volunteer work or paid employment, please detail what course of work that is here.Are there any other agencies or organisations currently or previously involved with this consumer? Please enter the information below.*Agency Name, Contact Person, Year involvedReferrer DetailsToday's Date* Name of Referrer* Organisation Contact Number* Whanau/Emergency ContactNext of Kin/Whanau Contact Person* Contact Number* Relationsip to Referral* Email Address* Physical Address* Street Address Address Line 2 City Clinical DetailsClinical Details Psychiatrist CMH Case Manager Does the consumer have, as part of their support, any of the following?Clinical Details continuedIf you ticked any of the above, please name the psychiatrist or CMH Case ManagerDiagnosis / Presumed Illness / Reason for your referral to our service*Please enter the reason you are referring to our service including any immediate concerns.Treatment DetailsDoes the consumer have any allergies that you are aware of?* Yes No No sure sorry If answered yes, please provide more information in the box belowAllergiesPlease list any allergies that you are aware of.Medication/sPlease list any medications the consumer is currently taking or write "not known" if you are unsure.Is there anything else you would like to add?Eg; Advocacy, dietary, cultural needs, interpreter, sign language. Consent / Authorisation I am referring myself for support (self-referral) I am referring a consumer, family/whanau member whom I have concerns about and they are aware that I have sent a referral to Te Tomika Trust I am referring a consumer , family/whanau member but they are not aware that I have sent a referral to Te Tomika Trust Documentation AttachedSupporting Documents Needs Assessment Risk Assessment Relapse Prevention Plan Behaviour Support Plan I am attaching the following supporting documents.Signature Reset signature Signature locked. Reset to sign again Date* DD slash MM slash YYYY Te Tomika Trust Use OnlyDate Referral Received Outcome Accepted Declined
