07 578 9733

Referral – Kaupapa Maori Community Support Services

KM Community Support Team - Referral for support

  • Please complete the following information on the person you are referring to our service
  • DD slash MM slash YYYY
  • Please enter the tangata whaiora's GP and/or clinic details. If you do not know, please write "unknown".
  • If the consumer is involved in any education course, volunteer work or paid employment, please detail what course of work that is here.
  • Agency Name, Contact Person, Year involved
  • Referrer Details

  • Whanau/Emergency Contact

  • Clinical Details

    Does the consumer have, as part of their support, any of the following?
  • If you ticked any of the above, please name the psychiatrist or CMH Case Manager
  • Please enter the reason you are referring to our service including any immediate concerns.
  • Treatment Details

    If answered yes, please provide more information in the box below
  • Please list any allergies that you are aware of.
  • Please 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.
  • Documentation Attached

    I am attaching the following supporting documents.
  • DD slash MM slash YYYY
  • Te Tomika Trust Use Only

Contact Us

Ph 07 578 9733
Fax 07 577 3450
60 Grace Road Tauranga 3112