Referral Form

New Zealand Red Cross Refugee Trauma Recovery is not a crisis service. Please refer to an emergency service if there is immediate risk of self harm or harm to others. We offer counselling to people from a refugee background who present psychological symptoms as a result of having experienced or witnessed torture and/or traumatic events, prior to coming to New Zealand.

Please complete this form with as much information as possible. Fields marked with * are required fields.

Referrer details

Name of referrer*

Referrer's email address

Date

Agency

Referrer's job title

Referrer's telephone number

Referrer's facsimile number

Client details

Full name of client*

NHI number

Date of birth*

Gender

Male

Female

Address

Telephone number (preferred contact)

Telephone number (alternative contact)

Legal status

Permanent resident

Temporary visa holder

Asylum seeker

New Zealand citizen

Marital status

Married

Defacto relationship

Divorced

Widowed

Separated

Unknown

Date of arrival in New Zealand

Is client aware of and in agreement with referral?*

Yes

Number of family members living under the same roof as client

If known, please list all household members of the client, including their full name, age, gender and relationship to the client

Are there concerns about any other family members?

Yes

Please specify concerns

Please list all other relatives living in New Zealand

Client's support person in New Zealand

Does the client have any current support networks?

Yes

Past engagement with mental health agencies and/or other support agencies: Please provide details of the service and support received.

General Practitioner and address

Current medication

Employment

Yes

Days and hours of work If applicable

Attending English language classes?

Yes

Day(s) and time of English language classes

School/early childhood centre If applicable

Other study/training being undertaken

Cultural information

Client country of origin

Ethnicity

Religion

Language(s) spoken

Interpreter required

Yes

Preferred language for interpreting

Gender preference of interpreter

Male

Female

Gender preference of counsellor

Male

Female

Summary of issues Please include a brief outline of your concerns, acknowledgement of the client's torture/trauma history and any other serious health concerns that could have a direct impact on their mental health e.g. living with a serious chronic condition.

Please tick the following observations (you do not need to ask any questions), or spontaneous disclosures:

For child/youth referrals only

Parents/caregiver issues (mental health, financial, etc.)

Past

Current

Child protection concerns

Past

Current

Please specify

Do you have a copy of the Refugees as Survivors (RAS) Referral Summary?*

Yes

If you have a copy of the RAS Referral Summary please email it to francesca.faggioli@redcross.org.nz, andrea.witkowski@redcross.org.nz and chris.clarke@redcross.org.nz as soon as you have sent this referral. You can also fax it to 04 805 0351. Thank you.

Please note: If you would like a copy of this referral for your records, please print this page before sending.

New Zealand Red Cross Incorporated is a registered charity with the New Zealand Charities Commission (CC21860), making you eligible for a tax refund of up to a third of your donation. All transactions are billed in New Zealand dollars.

New Zealand Red Cross operates from 69 Molesworth Street, Thorndon, Wellington 6011, New Zealand.

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Referral Form

Referrer details

Client details

Cultural information

Please tick the following observations (you do not need to ask any questions), or spontaneous disclosures:

For child/youth referrals only