REFERRAL FORM

    ARATAKI MINISTRIES Ltd, PO BOX 5028, Whangārei 0140

    EMAIL referrals@aratakimin.co.nz

    Date *:

    Contact Number *:

    Name *:

    Current Address:

    D.O.B *:

    Email *:

    Reason for Referral *:

    Male / Female:


    Dependants / children living with you

    Child Name:

    Ages:


    Next of kin / whānau / family / other

    Name:

    Relationship:

    Address:

    Phone:

    * By completing this process you hereby give Arataki Ministries permission to contact your Next of kin / Whanau / Family / Other.


    Medical Information

    Medical Diagnosis Axis I *:

    Medical Diagnosis Axis II:

    Allergies:

    Substance Use:

    Keyworker name:

    Contact details:

    Psychiatrist name:

    Contact details:

    GP / Service:

    Contact details:

    Other Service:

    Contact details:

    * Any risks or concerns to be aware – this includes forensic history


    What support do you require?

    I need support with:

    What does that look like to you?

    Housing Requirements - What does housing look like for you?

    House / Unit / Flat?:

    Shared / Communal Accommodation? :

    How many occupants?:

    How many bedrooms?:

    Preferred Location?:

    How much rent can you afford?:

    Are you a smoker?:

    Any pets to disclose?:

    Any additional / special housing requirements to be aware of?:


    Name of Referrer *:

    Contact number:

    Organisation / role:


    Attached information

    Pdf up to 2MB in size each

    Adult History / Summary of situation:

    Current Risk Assessment / Safety Plan:

    Other Relevant Assessments:

    Forensic History / Risks:

    Early Warning Signs / Relapse Prevention Plan:

    SNAP: