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Ka Pou Whenua Referral

Ka Pou Whenua Online Referral Form

Important: (Required)

This referral has been accepted over the phone by a Purapura Whetu Clinician or Kaimahi.

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?(Required)

Referrer Details

First name(Required)

Last name(Required)

Organisation: (Required)

Phone:(Required)

CR ACNM 021 598 602

Other

Phone(Required)

Email:(Required)

cdhb-mhcr@cdhb.health.nz

Other

Email(Required)

Tangata Whaiora Details

The tangata whaiora has given informed consent for the referrer to share relevant information with Ka Pou Whenua.

Full Name (Required)

Birthday

Day

Month

Year

Gender(Required)

Female

Male

Non-Binary

Address(Required)

Email

Phone(Required)

Text message okay?(Required)

Yes

No

NHI: (Required)

Ethnicity (Required)

Iwi

Hapu

Language(s)

Next of Kin/Contact Person

Full Name (Required)

Relationship to Whaiora(Required)

Phone(Required)

Email(Required)

Referral Details:

Name of GP, Medical Centre and Contact Details.

Current Situation(Required)

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

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

Please list all current and/or historical mental health diagnosis:

If applicable, please briefly state current substance abuse

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.

Please upload safety plans or other relevant information here:

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