youth referral – taranaki primary connections

When form is complete please scan or send as an email attachment to , deliver to Tui Ora main reception, 36 Maratahu St, New Plymouth or post to PO Box 8119, New Plymouth 4342

Name* / Date of Birth* / NHI
Address* / Gender / Date of application*
Phone / Mobile
School*
Name of GP/Practice*
Ethnicity: NZ Māori ☐NZ European ☐Other ☐
Name of legal parent/caregiver* / Parent/Caregiver contact number*
Referrer* / Position* / Organisation*
Referrers Contact number* / Referrers email address*
Summary of presenting issues*please specify or circle related options below:
#Adjustment Reaction #Anxiety #Depression #Grief #Mixed Anxiety & Depression Disorder #Alcohol/drug abuse #Postnatal Depression #Relationship Problems #Stress Related Problem #Other (describe) #Self Harm
Please note - TPC criteria excludes:
Developmental and/or behavioural issues; urgent crisis intervention; patient is displaying signs of suicidal intent; severe mental health/alcohol and drug presentation; serious risk of harm to others; eating disorders
Duration of Current Presenting Issues:
(date/months/years)
Please note TPC is for people with mild to moderate mental health issues only
Relevant social information* (please state why this client has been referred):
Is there a pre-existing MH diagnosis/relationship with Secondary MH services/crisis team? Please specify
Other concurrent or additional referrals made, or other agencies involved? Please specify
Youth Health Assessment and/or other information attached* (please circle): Yes No
E.g. Heads assessment, PHQ9, K10 and/or GAD scores.
Please note: this information is mandatory and if it’s not attached your referral will be returned requesting this information.
Medical History:
Long term conditions and/or medications:
Consent:
By submitting this referral, the referrer has obtained informed consent, and that the referred person is competent to provide his/her own consent regardless of age. Any immediate risk to self and others has also been assessed by the referrer.
If client is 12-16 years old: Has parent/caregiver consent been given? Yes / No
Parent Full Name*______
Parent Signature*______Date ______
Student Consent
Student full name *______
Student Signature*______Date ______
Please check to ensure all questions with * next to them have been completed before submitting as they are mandatory.
I confirm this patient is:
  1. Enrolled with a practice and therefore eligible for publicly funded health service
  2. Unable to afford the cost of private counselling
  3. Not eligible for any other funded psychology or counseling services e.g. EAP, Family Court
Referrer Signature*______Date ______
Referrer Name/Organisation/stamp______

QMS:Form/Service Delivery/Youth Referral – Taranaki Primary Connections (VERSION 1)Page 1 of 2