Youth Referral - Taranaki Primary Connections
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* / NHIAddress* / 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:
- Enrolled with a practice and therefore eligible for publicly funded health service
- Unable to afford the cost of private counselling
- Not eligible for any other funded psychology or counseling services e.g. EAP, Family Court
Referrer Name/Organisation/stamp______
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