Avodah Spiritual Respite Agency Referral Form
If you are a government or social agency and would like to refer a client to us, please fill out this form providing all relevant information about the person you are referring. IMPORTANT UPDATE Dated 17 July 2024 Due to high demand, current placement levels and constraints placed on us by the need for staff training and upgrades to our facilities we regret that we are unable to accept any more referrals for placement until the end of the year. We sincerely regret any inconvenience caused by this. Your information and application will still be processed and stored. Please don't hesitate to reach out for other support if you need to. We will send out further updates later in the upcoming months, so make sure you've signed up to receive our newsletter.
CLIENT DETAILS
Date of referral
Full name
Email (if known)
Phone Number (if known)
Address
Date of birth
NHI
WINZ Client Number (if known)
Ethnicity
Iwi (if known)
Gender
Female
Male
Other
Unspecified
Marital Status (if known)
Married
Single
Other (Civil Union, De Facto)
REFERRER DETAILS
If you are a government or social agency and would like to refer a client to us, please fill in the fields in this section.
Referrer Full Name
Organisation / Your Role
Referrer Phone Number
Referrer Location
Referrer Email
Is the client aware of this referral?
Yes
No
Don't know
Would you like feedback on this referral?
Yes
No
MEDICAL DETAILS
It is important that we have these details in order to ensure the applicant is eligible for placement.
Doctor (GP), Clinic or Health Provider
Please describe any known mental health difficulties or symptoms
Is the client currently on any prescribed medication? (Put No or Yes with details)
Current substance use (if known)
Other agencies involved (if known)
Safety concerns (Answer N/A or Yes and details)
Additional information
Upload File 1
Select a File
Accepted file types: doc, docx, pdf, Max. file size: 50 MB. Additional files can be sent via email.
Upload File 2
Select a File
Accepted file types: doc, docx, pdf, Max. file size: 50 MB. Additional files can be sent via email.
Upload File 3
Select an image file
Accepted file types: jpg, png. Max. file size: 50 MB. Additional files can be sent via email.
I want to subscribe to the mailing list.
I (the participant) give my consent for Avodah Charitable Trust to contact the relevant organizations and collecting information on my/their behalf.
AVODAH SPIRITUAL RESPITE KAIKOURA (Avodah Charitable Trust)
c/- 23 Bay Paddock Rd, Hapuku, Kaikoura Email: admin@avodah.nz
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