Client Referral Form

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

Referrer Contact Details


Client Details

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


Alcohol Use


Violent or Agressive Behaviour


Mental Health Issues


Other Known Risks


Covid-19 Questions

Symptoms


Vaccination Status


We strongly encourage you to get vaccinated before you attend our programme. Please visit: www.covid19.govt.nz to book your vaccination now online or or phone 0800 28 29 26. It is free to book your vaccination.


Hand Sanitising

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


Face Masks

Depending on Covid-19 Restrictions, the Government may make face mask wearing mandatory.

Please note also that you may request a face mask from us at anytime if you prefer to wear one, irrespective of Covid-19 Restriction Levels

Health & Safety Compliance

Parent / Guardian Details

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


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.


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

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