- KotahiConnect

Te Kotahi o Te Tauihu Charitable Trus - Referrals Service - Referral

Please fill in all required fields.

Self-Referral Referring yourself, or your whānau

Service Provider Referral Referring one of your clients.

Referrer Details

Provider Details

First Name

Last Name

Organisation Name

Contact Details

Phone Number

Email Address

Address

Physical Address

Address 1

Address 2

Suburb

City

Post Code

Postal Address is the same as Residential Address

Client Details

Personal Details

First Name

Middle Name(s)

Surname

DOB

NHI

Gender

Ethnicity1

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Contact Details

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Other Phone

Email Address

Address

Residential Address

Address 1

Address 2

Suburb

City

Post Code

Postal Address is the same as Residential Address

Referral Details

Referral Information

Reason for Referral (please be detailed so we can help identify the right service for you (if self referral) or your client (if 3rd party referral) Additional Notes: (Include any relevant background information)

Client Consent

I the client confirm the consent to disclose information has been discussed with me. I have been informed TKOTT is bound by law to uphold the Health and Disabilities Act; the Oranga Tamariki Act; and the Family Violence Act which means if kaimahi believe or witness there is harm to self and / or others this will be reported to the appropriate authorities.

By signing this form, I give consent for TKOTT to:

·       Provide services to me, including transport if needed.
·       Contact relevant service providers, NGOs, or government services to facilitate my care.
·       Store and manage my information securely, respecting my privacy.

Consenting Client (Print Full Name)

I consent to the above:

Yes No