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Intake Referral Form

Intake Referral Form Template for New Zealand

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Key Requirements PROMPT example:

Intake Referral Form

"I need an Intake Referral Form for a mental health service provider in Auckland, with emphasis on youth services and cultural support for Māori clients, ensuring compliance with the latest privacy regulations and including comprehensive risk assessment sections."

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Document background
The Intake Referral Form serves as a standardized document for initiating client services and facilitating transfers between service providers within New Zealand's healthcare and social services system. This document is essential when a client requires new services, needs to be transferred between providers, or requires coordinated care across multiple agencies. The form ensures compliance with New Zealand's privacy and healthcare regulations while capturing comprehensive client information, including demographic details, presenting issues, risk factors, and consent. It is designed to support proper assessment and service matching, particularly important in situations where multiple services or agencies are involved in client care. The Intake Referral Form includes specific sections addressing cultural considerations, particularly important in the New Zealand context with respect to Māori health and cultural needs.
Suggested Sections

1. Referral Details: Date, time, urgency level, and referring organization/professional's details

2. Client Information: Basic demographic information including full name, date of birth, NHI number, contact details, and address

3. Primary Contact: Emergency contact details and relationship to client

4. Cultural Considerations: Ethnicity, iwi affiliations, language preferences, and cultural support needs

5. Reason for Referral: Primary presenting issues and specific support/services requested

6. Current Situation: Brief description of current circumstances and immediate needs

7. Risk Assessment: Identification of any immediate risks to client or others

8. Current Supports: Existing services, support networks, and other involved professionals

9. Medical Information: Relevant medical history, current medications, and allergies

10. Privacy Statement: Information about how client data will be used and shared

11. Consent: Client authorization for referral and information sharing

Optional Sections

1. Mental Health Status: Details of mental health history and current status - include when referring for mental health services

2. Disability Support Needs: Specific disability-related requirements - include when client has disability support needs

3. Legal Status: Information about legal orders or requirements - include when there are legal considerations

4. Housing Status: Current living situation and housing needs - include when housing is a factor in service provision

5. Financial Information: Financial situation and support needs - include when financial assistance may be required

6. Education/Employment Status: Current education or employment situation - include when relevant to service provision

7. Whānau/Family Assessment: Extended family situation and needs - include when family-centered approach is required

Suggested Schedules

1. Risk Assessment Form: Detailed risk assessment template for high-risk cases

2. Consent Forms: Additional specific consent forms for information sharing with particular agencies

3. Cultural Support Plan: Detailed cultural considerations and support requirements

4. Safety Plan: Comprehensive safety planning document for at-risk clients

5. Medical Information Release: Detailed medical information release forms

6. Privacy Statement Details: Complete privacy policy and information handling procedures

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant legal definitions
Referrer
Client
Service Provider
Personal Information
Health Information
Urgent Referral
Non-Urgent Referral
NHI Number
Primary Contact
Whānau
Cultural Support
Informed Consent
Privacy Statement
Risk Assessment
Support Services
Treatment Plan
Care Coordinator
Emergency Contact
Legal Guardian
Mental Health Act
Primary Healthcare Provider
Presenting Issues
Referral Period
DHB
Iwi
Tikanga
Support Network
Information Sharing
Confidentiality
Service Level
Assessment Process
Crisis Response
Cultural Safety
Next of Kin
Medical History
Relevant Industries

Healthcare

Mental Health Services

Social Services

Disability Support Services

Community Services

Elder Care

Youth Services

Addiction Services

Primary Health

Allied Health

Cultural Support Services

Family Services

Relevant Teams

Intake and Assessment

Clinical Services

Social Work

Primary Care

Mental Health

Community Support

Care Coordination

Cultural Support

Administration

Quality Assurance

Client Services

Referral Management

Relevant Roles

Social Worker

Case Manager

Healthcare Coordinator

Clinical Director

Intake Coordinator

Mental Health Professional

General Practitioner

Nurse Practitioner

Allied Health Professional

Cultural Support Worker

Service Manager

Referral Coordinator

Community Support Worker

Healthcare Administrator

Clinical Assessor

Whānau Ora Navigator

Industries
Privacy Act 2020: Governs how personal information is collected, used, stored, and shared. Essential for ensuring proper handling of client information in the referral form.
Health Information Privacy Code 2020: Specific rules for handling health information, including consent requirements and information sharing between healthcare providers.
Health and Disability Commissioner Act 1994: Establishes rights of health and disability services consumers, including the right to be fully informed and make informed choices.
New Zealand Bill of Rights Act 1990: Ensures protection of fundamental human rights, including right to refuse treatment and non-discrimination in service provision.
Health Act 1956: Provides the framework for health services in New Zealand and requirements for health information management.
Health Practitioners Competence Assurance Act 2003: Relevant for professional requirements if the referral form is used by registered health practitioners.
Human Rights Act 1993: Ensures non-discrimination in access to services and equal treatment regardless of personal characteristics.
Mental Health (Compulsory Assessment and Treatment) Act 1992: May be relevant if the intake referral form is used for mental health services.
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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