Referral Form – villagecollective.codedna.site

WHO IS THIS FOR?*

It's for myselfI'm making a service referalIt's for a family member or friend

Does this person know that you are referring them to our services?

Please speak to the person you wish to refer and notify them before referring.

VC Clinic Referring Family or Friend Form

Referred is 16 years old and UNDER By ticking this you confirm that the information provided in this referral form has been shared with the young person’s legal guardian(s)Referred is OVER 16 years of age By ticking this you confirm that the information provided in this referral form has been shared with the person

REFERRER INFORMATION

Name*

Organization (if applicable)

Role/Relationship to client

Phone Number*

Email Address*

CLIENT INFORMATION

Full Name*

Date of Birth*

NHI Number (if known)

Gender*

Trans / Non-Binary / Another Gender

Ethnicity / Cultural Identity

Preferred Language*

Interpreter Required?*

Address

Phone Number*

Email Address (if any)

Preferred Contact Method*

Is it safe to contact client directly?

Emergency Contact (Name & Number)

GP / Primary Healthcare Provider

REASON FOR REFERRAL

General Health Check-UpSexual Health Check-UpPsychologist / Talanoa SessionPacific Rainbow+ Youth Skills GroupPeer SupportOther (please specify)

Additional details (symptoms, concerns, or context):

SERVICE SPECIFICS

URGENCY OF REFERRAL

RoutineWithin 1 weekImmediate

SERVICES REQUESTED

STI ChecksContraception AdviceCounselling / Psychologist SessionHealth ChecksWellbeing SupportPacific Rainbow+ Youth Skills Group (Sei Lelei)Other

HAS THE CLIENT PREVIOUSLY ENGAGED WITH VILLAGE COLLECTIVE?

YesNoNot Sure

HOW DID YOU HEAR ABOUT US?

CONFIDENTIALITY

I understand this information will be kept confidential and used only for the purpose of referral.

If you, or someone you care for, is interested in accessing these supports, complete the form below

This form takes approximately 10-15 minutes to complete. Ensure you answer all applicable questions, some questions are mandatory.

We are here to help if you have any questions regarding this form or our referral process feel free to contact us via email at clinic@villagecollective.nz or phone 027 275 6448.

WHO IS THIS FOR?*

REFERRER INFORMATION

CLIENT INFORMATION

REASON FOR REFERRAL

SERVICE SPECIFICS

CONFIDENTIALITY

Address

Contact

Office Hours