top of page

Home
Our Team
Referrals
News & Updates
Contact

Kā Pou Whenua Referral

Important: This online referral form should only be completed if a phone call has been made to Ka Pou Whenua and accepted over the phone first.

Who did you speak to in the above phone call?*

Referrer Details

First name*

Last name*

Organisation*

Phone *

CR ACNM - 021 598 602

Other

Referrer Phone Number *

Referrer Email:*

Tangata Whaiora Details:

Informed consent: referrer to share relevant information with Ka Pou Whenua.

Full name*

Birthday*

Day

Month

Year

Gender*

Male

Female

Non-Binary

Address*

Email

Phone

Test message okay? *

Yes

No

NHI*

Ethnicity*

Iwi

Hapu

Languages

Next of kin or contact person/people

Full name: *

Relationship*

Phone: *

Email: *

Referral Details:

Name of GP, Medical Centre and Phone

Current Situation*

Briefly describe the persons current mental health experience or psychosocial challenges.

Does the person have a current or historical mental health diagnosis?

Please list all current and/or historical mental health diagnosis

Briefly state current substance use (If any)

Is there an immediate suicide risk?

Are there other services currently involved with this person?

What Services are currently involved with this whaiora?

Does the Whaiora have a current safety plan?

Additional Comments/Notes.

Upload safety plans or other relevant information here:

Consent: Information: I agree that my information may be shared with other staff of Purapura Whetū for the purposes of my participation in Ka Pou Whenua.

bottom of page

​Kā Pou Whenua Referral

Next of kin or contact person/people

Referral Details:

Kā Pou Whenua Referral