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Client Referral Form

Please fill out the online form below, by filling in each section and clicking NEXT once you have completed each part.

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Client Details
Client Risk History
Your Wellbeing
Parent/Guardian Contact Details

Date of Referral *

Referral Source *

Self

Family/Whanau

Oranga Tamariki

Police

WINZ

School

Alternative Education

NGO Provider

Other (please specify)

If Referral Source is Other, please specify

Referrer Contact Details

First Name *

Last Name *

Landline

Mobile *

Physical Address (including suburb) *

Email Address (please provide contact email of client): *

Programme Name for Referral *

Drivers License Programme (Learners License)

Driving School (Restricted License)

Driving School (Full License)

HAZCAR (1 Day Course, Driver Hazards, Driver Safety & General Car Maintenance)

Client Details

First Name *

Last Name *

Gender *

Age (years) *

D.O.B *

Landline

Mobile *

Physical Address *

Client Email Address *

Ethnicity *

NZ European/Pakeha

Maori - Please enter any iwi affiliations below

Samoan

Cook Island Maori

Tongan

Niuean

Indian

Chinese

Korean

South African

Other

If ethnicity is Maori, please list iwi affiliations below (optional)

If ethnicity is Other, please state below

First Language *

Client is currently employed? *

Yes

No

If currently employed, please state occupation

Please state employer name

Client is currently in the care of Oranga Tamariki Care and Protection? (including with foster parents) *

Yes

No

If Yes Please Provide Details

Client is currently in a Oranga Tamariki Care and Protection Residential Facility? *

Yes

No

If Yes, please write the name of the facility

Client is currently in a Youth Justice Residential Facility? *

Yes

No

If Yes Please Provide Details

Next

Client Risk History

It is essential that all known risks are disclosed whether current or previous.

Please disclose all current and past risks and hazards known about the client:

Drug Use

Has The Client Ever Been Involved in Drug Use? *

Yes

No

If Yes, is this a current risk OR past risk?

Current Risk

Past Risk

Please list any drug assessment reports available

Alcohol Use

Has The Client Ever Been Involved in Alcohol Use? *

Yes

No

If Yes, is this a current risk OR past risk?

Current Risk

Past Risk

Please list any alcohol assessment reports available

Violent or Agressive Behaviour

Has The Client Ever Been Involved in Violent Or Aggressive Behaviour? *

Yes

No

If Yes, is this a current risk OR past risk?

Current Risk

Past Risk

Please list any reports which describe past or current violent or agressive behaviour:

Mental Health Issues

Does The Client Have Any Mental Health issues? *

Yes

No

If yes, please state mental health issues:

If Yes, is this a current risk OR past risk?

Current Risk

Past Risk

Please list any mental health assessment reports for this client:

Other Known Risks

Are There Any Other Risks Not Already Disclosed Earlier? *

Yes

No

If yes, please state other risks:

Does The Client Currently Smoke Tobacco? *

Yes

No

Is The Client Currently on any Form of Medication? *

Yes

No

If Yes, please list medications:

Does The Client Have Past Criminal Offences? *

Yes

No

If Yes, please list all Criminal Convictions and Year Convicted

Is The Client Facing Current Charges with The Court? *

Yes

No

If Yes, please state what charges are being faced:

If Yes, please state any confirmed court dates:

Next Previous

Your Wellbeing

Symptoms

Do you have any of the following symptoms (even if symptoms are mild) now or in the past 7-days?

Fever

Cough

Cold or congestion

Sore throat

Runny nose

Body aches

Headache

Loss of smell

Loss of taste

Vomiting

Diarrhea

Tiredness

Skin rash

Have you tested positive for Covid-19 within the last 7 days? *

Yes

No

Signing-in

It is mandatory for all clients and visitors to sign our visitor register when entering our facility.

Please confirm that you agree to comply with this requirement *

Yes

No

Hand Sanitising

We require all staff, clients and visitors to hand sanitise when entering our facility, and hand sanitiser is located at the entrance.

Please confirm that you will comply with our safe practise procedures when entering our facility: *

Yes

No

Face Masks

We may require you to wear a face mask when attending our programmes. This is not limited to only Government restrictions (if applicable) as we maintain our own health and safety policies and procedures. We may refuse you entry to our programmes if you refuse to comply with any request to wear a face mask.

Please confirm that you will comply with this requirement if required or requested either prior to attending or while participating in our programmes? *

Yes

No

Please note also that you may request a face mask from us at anytime if you prefer to wear one to maintain your own wellbeing

Health & Safety Compliance

Do you agree to comply with our health and safety procedures and any instructions provided by our staff while being on our programme? *

Yes

No

Next Previous

Parent / Guardian Details

Please note that this person will also be the first point of contact in an emergency.

Parent or Guardian? *

Parent

Guardian

If Guardian, please state relationship to client:

Does the Parent or Guardian currently live with the client? *

Yes

No

First Name *

Surname *

Physical Address *

Landline - Please include area code

Mobile *

Alternative Phone Number

Second Point of Contact Details

Please provide a second point of contact in case we are unable to reach the primary contact in case of emergency.

First Name *

Surname *

Relationship to client *

Physical Address *

Landline - Please include area code

Mobile *

Alternative Phone Number

Please state what the main reason is that the client wishes to come on the programme? *

To complete this referral, please hit "Send Referral Now"

How Did You Hear About Us? *

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