TE WHARE ORANGA NGAKAU REFERRAL FORM

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Transcription:

TE WHARE ORANGA NGAKAU REFERRAL FORM REFERRER INFORMATION REFERRAL FROM: NAME: POSITION: POST CODE: PHONE NO: FAX NO: CLIENT INFORMATION CLIENTS FULL NAME: DATE OF BIRTH: PHONE NO: POST CODE: ETHNIC GROUP: NHI NO: LEGAL HISTORY (To include transcript of charges, convictions, terms of incarceration charges/court cases pending) DIC s/eba s: ALCOHOL/DRUG RELATED: OTHER: Issue Date: Jan 2018 Review Date: Jan 2020 Version: 5 Page 1 of 6

CURRENT LEGAL STATUS PAROLE: SUPERVISION WITH CONDITIONS: BAIL (including photocopy of Bail papers): AWAITING SENTENCE AT DISTRICT/ HIGH COURT ON: LAWYER: PHONE: FAX: PROBATION OFFICER: PHONE: FAX: COURT DATES PENDING DURING RESIDENTIAL STAY: YES: NO: If YES please provide: DATE: TIME: REASON FOR REFERRAL: (e.g. Court, Referral, Client motivated) PREVIOUS ATTENDANCE AT ANY ALCOHOL AND DRUG TREATMENT CENTRE: (e.g. Where? When? Outcome?) Issue Date: Jan 2018 Review Date: Jan 2020 Version: 5 Page 2 of 6

ALCOHOL AND DRUG HISTORY (To include history of use, current patterns of use and diagnosis in accordance with DSMIVR) Alcohol SUBSTANCES AMOUNTS FREQUENCY LAST USED Marijuana, Cannabis Oil Prescription Pills Narcotics IV Usage Solvents Gambling Other: Please include Assessment tool/screen results MEDICAL HISTORY (To include medical history, Hep A, B or C and/or HIV status, current prescribed medications, medication allergies (if any), blood test results. Note: Scripts and blister packs are compulsory for the duration of the programme) GP NAME: PHONE: FAX: POST CODE: Issue Date: Jan 2018 Review Date: Jan 2020 Version: 5 Page 3 of 6

PSYCHIATRIC HISTORY/MAJOR MENTAL ILLNESS (To include any contact with Mental Health Services, any issues of self-harm e.g. cutting, burning, violence to others, any suicidal thoughts, attempts? Diagnosed Where and When?) KEYWORKER: MEDICATION: RESPONSIBLE CLINICIAN: MENTAL HEALTH ACT STATUS: TRANSFER OF CARE: (Initiated/Completed For clients with Co-existing Disorders as directed by a Compulsory Treatment Order) TREATMENT PLAN: WHANAU/SUPPORT: (To include any Significant Others included in Client s Treatment Plan) CULTURAL ISSUES/NEEDS: EMPLOYMENT: CURRENT: BENEFIT TYPE: PREFERRED TREATMENT PAYMENT OPTION: ACC: NZ BENEFIT: PRIVATE PAYING: (i.e. Overseas Benefit) OTHER COMMENTS: (i.e. Referrer s impression) Issue Date: Jan 2018 Review Date: Jan 2020 Version: 5 Page 4 of 6

DOCUMENTS REQUIRED FOR CO-EXISTING DISORDERS (1) Recent Psychiatric Assessment last Out Patient appointment notes (2) Crisis Management Plan (3) Prescription when admitted (Note: blister pack medication is compulsory) DISCHARGE PLAN (Accommodation, transport and follow up arrangements) UPON GRADUATION: UPON EARLY EXIT FROM PROGRAMME: CLIENT DECLARATION (1) I agree to the above referral information being given to Te Whare Oranga Ngakau. (2) Upon my discharge from Te Whare Oranga Ngakau, I agree to Te Whare Oranga Ngakau giving relevant information back to my referrer, regarding my attendance, treatment and discharge address. CLIENT SIGNATURE: DATE: COMPLETED BY: DATE: NOTE: Admission dates are only tentative, pending receipt of typed Comprehensive Assessment information. Issue Date: Jan 2018 Review Date: Jan 2020 Version: 5 Page 5 of 6

CLIENT DETAILS FULL NAME: POST CODE: DATE OF BIRTH: DAY TIME PHONE NO: ADMISSION DATE TO THE PROGRAMME: BENEFIT: YES: TYPE: NO: POW: CLIENT WINZ NO: - - YES NO IS WINZ PAYING COURT FINES FROM CLIENT S BENEFIT? IS WINZ PAYING CHILD SUPPORT TO IRD FROM CLIENT S BENEFIT? TELEPHONE AUTHORISATION (CONSENT TO CONTACT WINZ, IRD ETC) ANY ONGOING PAYMENTS FOR: YES NO RENT: BOARD: STORAGE: OTHER (PLEASE STATE): ANY OTHER PERTINENT FINANCIAL INFORMATION? Issue Date: Jan 2018 Review Date: Jan 2020 Version: 5 Page 6 of 6

CLIENT SIGNATURE: DATE: Issue Date: Jan 2018 Review Date: Jan 2020 Version: 5 Page 7 of 6

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