TANGATA WHAKAATURANGA (WHĀNAU MEMBER DETAILS)	NHI Number: DATE:
Ingoa Tuatahi (First Name):	Ingoa Whānau (Last Name):
Waahi Kāinga (Address):
Waea Kāinga (Home Phone):	Waea Pūkoro (Mobile):
Rā Whānau / Date of Birth:	☐ Tane / Male ☐ Wahine / Female	Iwi/Nō Wai / Ethnicity: ☐ Māori Iwi/Hapu: _______________________________________ ________________________________________________________ ☐ Pacific Island ☐ Asian ☐ NZ European ☐ Other
Age and gender of any dependent children
Office use: Other information
TAKUTA WHAKAATURANGA (GP DETAILS):
Ingoa (Name of GP):	Nama Waea (Phone Number):
WHĀNAU TAUTOKO (ALTERNATIVE WHĀNAU CONTACT):
Ingoa Tuatahi (First Name):	Ingoa Whānau (Last Name):
Waahi Kāinga (Address):
Waea Kāinga (Home Phone):	Waea Pūkoro (Mobile):
TARI-TUKU WHAKAATURANGA (REFERRER DETAILS):
Tari-tuku (Referring Agency):
Tangata i tuku (Referrer Name):
Kāinga Imeera (Email Address):
Nama Waea (Phone Number):	Waea Pūkoro (Mobile): ;:

KO TEHEA ROHE I HIAHIATIA AI? Email Address:	☐ WAIRAU (Blenheim) referrals.wairau@tpo.org.nz	☐ WHAKATŪ (Nelson) referrals.whakatu@tpo.org.nz	☐ MOTUEKA referrals.motueka@tpo.org.nz
Fax Number:	Fax: 03 578 5980	Fax: 03 548 4248	Fax: 03 528 1155
KO TEHEA TARI I HIAHIATIA AI (SERVICES REQUIRED):
☐ Ngā Pūkenga Atawhai (Community Nurse) ☐ Tamariki Ora (WellChild 0–5 Years) ☐ Outreach Immunisation (Wairau only)	☐ Ngā Pūkenga Toitu Te Ora a Waipiro me Tarutaru kino (AOD Counsellors) ☐ Ngā Pūkenga Hauora Hinengaro o nga Tamariki me Rangatahi (CAMHS)	☐ Te Hā Aukati Kaipaipa (Stop Smoking) ☐ Cervical Screening ☐ Ngā Pūkenga Manaaki (Navigators)

WHAKAAETANGA (WHANAU CONSENT):
Whānau aware of this referral? Y/N	Whānau given permission to be contacted? Y/N
TUKUNGA-O-WAHO (EXTERNAL REFERRAL) - ☐ YES ☐ NO
PŪTAKE MŌ TE TUKU MAI (REASON FOR REFERRAL):
Concerns that have prompted this referral? (Please provide detailed information for the specific service you require as well as and including any ‘Risk Factor’ information that may be useful when working with your referral.)
Are there any possible safety concerns/risks for our kaimahi (staff) that we should know about?
KO ĒHEA ATU TARI E TAUTOKO NEI (OTHER AGENCIES/SERVICES CURRENTLY INVOLVED):
Tēnā, whakamāramatia (Please Specify):

☐Would you like to subscribe to our Te Puna pānui/newsletter?

FOR OFFICE USE ONLY
Referral: ☐ Accepted ☐ Declined	Referrer Informed? Y/N If Yes – Date: