CLIENT DETAILS
Referral Date:
Date of Birth:
Surname:
Phone No:
First Name(s):
NHI No:
Address:
CSC No:
Expiry Date:
Ethnicity:
NZ Residency:	Yes	No
Iwi:
Gender:	M	F
GP:
First Language:
Communication Method (Interpreter Required):
If the person has been identified as Maori would they like a culturally appropriate facilitator?

Yes	No
Present Living Situation:

Living With:	Alone	With Spouse/Partner	With other family members	Others
Risk Factors:	Yes	No

If yes, please identify:

Please attach documentation detailing risk and safety concerns and supports that are being utilised to manage these risks.
IMPORTANT: Has the person you are referring given consent to disclose their information, and are they requesting this service?	Yes	No

If consent has not been obtained, give reason:

ALTERNATIVE CONTACT PERSON/NOK DETAILS
Surname:
Title:
First Name(s):
Address:
Relationship:
Phone Number:
DISABILITY DETAILS

Please attach confirmation of diagnosis from a specialist and any other supporting reports
Primary: Include date of event or diagnosis

Secondary: Please use this section to outline any medical, mental health or ACC/Accident related conditions

Reason for Referral: Please outline the reasons for this referral, indicating the loss of function and its expected duration, and how this related to the stated disability.

Urgency of Referral:

Non Urgent	Semi Urgent	Urgent
Additional Info: Please provide any additional information you feel is relevant to this referral.

HEALTH INVOLVEMENT DETAILS
Specialist Clinician:
ACC:
Social Worker:
Psychologist:
Therapists:
Paediatrician:
Agency/Organisation:
Other:
HOSPITAL DISCHARGE DETAILS
Proposed Discharge Date:
Short term services in place?

Yes	No	Start Date:	End Date:
REFERRER DETAILS
Name:
Agency
Address:
Phone:
Email:
Fax:
Relationship to Client:

Office / audit use only

Referral received by:	Email	Fax	Post	Date received:
Contact made within 2 working days?	Yes No	Referral acknowledgement letter & brochure sent:	Yes No
Date entered into database:
Team Manager:

LifeLinks
Nga Oranga Mekameka
A Division of Compensation Advisory Services Ltd

Disability Support Services Referral Form

0 – 65 years

Tuku Tono Mō

42 Buchan Street, PO Box 2379, CHRISTCHURCH

Ph: (03) 365 9593, 0800 866 877, Fax: (03) 365 5244, Email: referrals@lifelinks.co.nz

QCMA-Version 1 – 1/7/11

Pene Maddock

2018-08-28

Lifelinks