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Client Information
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Name
Date of birth
Phone number
Gender
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Female
Gender Diverse
Address
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Ethnicity
Admiralty Islander
Afghani
African American
African (NFD)
Aitutaki Islander
Albanian
Algerian
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Arab
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Asian (NFD)
Assyrian
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Australian
Australian Aboriginal
Austrian
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Belau/Palau Islander
Belgian
Bengali
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Black
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Brazilian
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British (NFD)
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Burmese
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Central American Indian
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Chilean
Chinese (NEC)
Chinese (NFD)
Colombian
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Costa Rican
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Creole (US)
Croat/Croatian
Cypriot (NFD)
Czech
Dalmatian
Danish
Dutch/Netherlands
Easter Islander
Ecuadorian
Egyptian
English
Estonian
European (NEC)
European (NFD)
Falkland Islander/Kelper
Fijian (except Fiji Indian/Indo-Fijian)
Fijian Indian/Indo-Fijian
Filipino
Finnish
Flemish
French
Gaelic
Gambier Islander
German
Greek (incl Greek Cypriot)
Greenlander
Guadalcanalian
Guam Islander/Chamorro
Guatemalan
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Guyanese
Hawaiian
Honduran
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Hungarian
Icelander
I-Kiribati/Gilbertese
Indian (NEC)
Indian (NFD)
Indonesian (incl Javanese/Sundanese/Sumatran)
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Irish
Israeli/Jewish/Hebrew
Italian
Jamaican
Japanese
Jordanian
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Kanaka/Kanak
Kenyan
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Korean
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Latin American/Hispanic (NFD)
Latvian
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Lithuanian
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Malaitian
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Malaysian Chinese
Maltese
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NOT SPECIFIED
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Chinese
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Japanese
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Referrer Information
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Who are you referring?
Yourself
A friend or family member (affected other)
A GP/Doctor or other service provider referring a patient
Please ensure you have permission to share this information with us
Are you an individual or agency?
Individual
Agency
Individual/Agency name
Referrer contact phone
Referrer email
Client Medical Information
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Name of GP/Doctor
Name of practice
GP/Doctor phone
GP/Doctor email
NHI number
Additional Details
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Current legal status in NZ
NZ Citizen
Permanent Resident
Working Visa
Student Visa
Visitor Visa
Name of next-of-kin
Email of next-of-kin
Current living situation
Living with others
Homeless
Own Home
Boarding house
Living with family/whanau
Currently smoking (in last 30 days)
Yes
No
Current employment status
Employed - working full-time
Employed - working part-time
Unemployed - not working
Family Information
Please enter the required fields
Is this person a parent/caregiver?
Yes
No
How many children are currently under their care?
How old are the children?
Do the children need support?
Yes
No
Reason for Referral
Please enter the required fields
What is the reason for referral?
Experienced gambling harm / Gambler
Affected by someone else's harmful gambling
Needs help with a mental health related issue
Other (social support)
Support needed
Problem gambling
Mental health issues
Generational relationship
Being social with others (group/activities)
Parenting
Legal issues
Alcohol and/or drug us
ACC eligible conditions (e.g. head injury)
My culture
Budgeting
Employment assistance/help finding a job
Couple's counselling
Peer support
Support with my wellness
Family violence issues
Education issues
Finding accomondation
Involvement with the legal system
Family/whanau and support people
Other (Please state)
Other support info
Would the Client prefer to speak to a male or female clinician/counsellor?
Male
Female
Any further details?
Please enter the required fields
Please use the box below to provide us with any further details that you think may be important.
Any further background information you can provide (i.e. the main issue of concern, or a program they/you may wish to attend).
Is this person a risk to them self or others (mental health organisations can attach a risk assessment and support plan); any medication the person is currently taking; any other agency who is currently involved, etc.
Background Information
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