ARATAKI MINISTRIES Ltd, PO BOX 5028, Whangārei 0140
EMAIL [email protected]
Date *:
Contact Number *:
Name *:
Current Address:
D.O.B *:
Email *:
Reason for Referral *: —Please choose an option—CSWHousingAOT
Male / Female:
NHI Number:
Child Name:
Ages:
-+
Name:
Relationship:
Address:
Phone:
* By completing this process you hereby give Arataki Ministries permission to contact your Next of kin / Whanau / Family / Other.
Medical Diagnosis Axis I *:
Medical Diagnosis Axis II:
Allergies:
Substance Use:
Keyworker name:
Contact details:
Psychiatrist name:
GP / Service:
Other Service:
* Any risks or concerns to be aware – this includes forensic history
I need support with: Being social with others (Groups / Activities)HousingMSD Payments / EmploymentFinances / budgetSupport with Daily LivingAge related issuesFamily / whānau and support peopleMy Spirituality / My CulturalInteracting with other people & environmentsAlcohol / drugs
What does that look like to 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 *:
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:
I give consent to submit this referral.
