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Arataki Living Rough Referral Form
Arataki Living Rough Referral Form
Arataki Living Rough Referral Form
Arataki Ministries
2025-03-09T15:04:57+13:00
Living Rough Referral Form
ARATAKI MINISTRIES Ltd
PO BOX 5028, WHANGAREI
(09) 4303044
(09) 4303544
[email protected]
Personal Details of Applicant
Name
(Required)
First Name
Surname
Phone Number
(Required)
Email
(Required)
Gender
(Required)
Date of Birth
(Required)
NHI
Ethnicity
(Required)
Emergency Contact
Next of Kin details
(Required)
Name
Relationship
Address
Phone
Add
Remove
Add
Remove
Consent
(Required)
By completing this process, you give us permission to contact your next of kin/whanau/significant other
Referrer details
Referrer Details
(Required)
Referrer Name
Relationship
Contact Number
Date of referral
Add
Remove
Add
Remove
Accommodation Requirements
Current Living Arrangements
Sleeping on Streets
Car/Mobile Home/Tent
Temporary Sharing
Couch Surfing
Other
Are you in the Whangarei Area
Yes
No
How long have you been in your current situation?
Less than 1 month
Six months or less
1 year or more
Declined to answer
Have you been homeless before?
Yes
No
Declined to answer
Medical Information
Medical Diagnosis
Allergies
GP/Service
GP/Service Contact
Substance Use
Medical Alerts (eg Diabetes, Epilepsy)
Please upload any relevant information
(Required)
Drop files here or
Select files
Accepted file types: pdf, jpg, png, Max. file size: 2 MB, Max. files: 5.
Client Consent
(Required)
I give consent to submit this referral form
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