Referral - Oranga Hinengaro

referral – oranga hinengaro

When form is complete please email it to Intake Co-ordinator , deliver to Tui Ora main reception, 36 Maratahu St, New Plymouth or post to PO Box 8119, New Plymouth 4342

Name: / NHI: / Date of Birth:
Address: / Gender: / Marital Status:
Phone Number(s):
Ethnicity: NZ Māori ☐ NZ European/Pakeha ☐ Pacific Islander ☐ Other ☐
Urgent ☐ / Semi-Urgent ☐ / Routine ☐ / New to TOL MH Yes ☐ No ☐
GP Service: / Contact Number:
Whānau Contact: / Address:
Relationship: / Phone Number(s):
Please identify service required:
☐ Co-Existing Disorders
☐ Consumer Advocacy
☐ Community Mental Health
☐ Day Activity and Living Skills
☐ Early Intervention Service
☐ Kaumātua and Kuia Service
☐ Mental Health of Older Persons
☐ Mobile Intensive Treatment Service
☐ Needs Assessment and Service Coordination
☐ Peri-Natal Mental Health
☐ Physical Health Outcomes Service
☐ Psychology
☐ Specialist Alcohol and Other Drug Service
☐ Vocational Support Service
☐ Whānau Kaitiaki / kaiāwhina
Referral from: TDHB ☐ Other MHA Service ☐
Other Agency:______
Current Situation and Risks:
Current Medication:
Previous/Current MH, NGO and other agencies involved:
Does Tangata Whai Ora consent to this referral? ☐ Yes ☐ No
Referrer Signature ______Date ______
Referrer Name/Organisation/stamp ______
Attached Documents / Yes / No / N/A
Clinical Management Plan
Risk Assessment
Relapse Prevention Plan
Other ______
Other ______ / ☐
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Oranga Hinengaro
Tui Ora provides a kaupapa Māori mental health assessment, intervention and consultation service. This service is supported by Kaumātua and Kuia as well as a vocational support service to tangata whai ora and whānau in the Taranaki region.
Aims of Service
We aim to increase tangata whai ora ability to recognize and manage their own mental health wellness by providing:
·  Tikanga Māori based clinical mental health services
·  Specialist assessment (clinical and cultural), diagnosis and associated wellness support plans
·  Medication and other treatments in accordance with wellness support plan
·  Advice on all matters relating to maintaining wellness

QMS:Form/Service Delivery/Referral – Oranga Hinengaro (VERSION 2) Page 2 of 2