SELF REFERRAL FORM
Use this form when you are applying for a placement at the Avodah Men's Christian Spiritual Respite. Please supply as much detail as possible as it helps us to help you. Consent: Nb. It is important consent is given for us to collect certain relevant information (if the participant is unaware that you have sent this referral you can do this on their behalf) Please tick the consent box below in this form. Avodah Charitable Trust (Avodah Christian Spiritual Respite) c/- 23 Bay Paddock Rd, Hapuku, Kaikoura Email: admin@avodah.nz Consent: It is vital that consent is given for us to collect certain relevant information. We cannot process your application without your consent. Please tick the consent box below in this form.
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. Links are on our website.
PARTICIPANT DETAILS
Your details - please supply as much information as possible.
Date of referral
Your Full Name
Your Preferred Name
Your Email Address
Phone Number
Please describe any known mental health difficulties or symptoms
Address
Date of birth
NHI
WINZ Client Number (if known)
Ethnicity
Iwi (if known)
Gender
Female
Male
Other
Unspecified
Marital Status
Married
Single
Other (Civil Union, De Facto)
Would you like feedback on this referral?
Yes
No
HEALTH PROVIDER DETAILS
Doctor (GP), Clinic, or Health Provider
Are you currently on any prescribed medication? (Put No or Yes with details)
Please describe any known mental health difficulties or symptoms
Is there any current substance abuse? (Put No or Yes with details)
Other agencies involved (Put No or Yes with details)
Safety concerns (Put No or Yes with details)
Additional information
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AVODAH CHARITABLE TRUST (Avodah Spiritual Respite Kaikoura)
c/- 23 Bay Paddock Rd, Hapuku, Kaikoura Email: admin@avodah.nz
Additional Information for applicants within the Justice or Prison system
Please supply further information if applicant is in the Justice or Prison system. In order to process your application we now require some additional details. It's important that you answer as many questions as possible to speed up the application and acceptance program. remember to tick the consent box at the end of this form.
Case Manager / Probation Officer Name & Location
Case Manager / Probation Officer email address
Prison or other institution
Lawyer
Police or Probation Officer - Safety Plan
Current Convictions /Charges
Total Prison Sentence and Sentence End Date
Parole Hearing Date (First)
Subsequent Parole Hearings (2nd, 3rd, 4th)
Time in Remand
Court appearance(s) (Dates / Location)
Support Person / Next of Kin (Full name) and email address)
Upcoming court or parole hearing conditions
Prison Programs / Prison Trade Programs / Prison Church Groups
Todays Date
I (the participant) give my consent for Avodah Charitable Trust to contact the relevant organizations and collecting information on my behalf.
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