Self-refer to Hauora Kai

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Waipuna Youth Services
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Eating Awareness, Hauora Kai
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Self-refer to Hauora Kai

Self-refer to Hauora Kai

You are welcome to self-refer to Hauora Kai. Referrals are also accepted from GPs, counsellors, schools, and other health professionals. Please complete the form below and our team will be in touch within 3 working days.

Date of Referral

Referrer(Required)

Self Referral

Family Member

Agency

Client Information

First Name

Last Name

Date of Birth(Required)

Age

NHI Number (if you know it)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Number

Best time to contact

Do you have an email address that we can send a confirmation and referral updates to?(Required)

Yes

Client Email Address

Please add your email so we are able to send you a confirmation email.

Gender from Birth(Required)

Male

Female

This information is used for reporting purposes

Gender you identify with

Pronouns

Ethnicity

Māori

Pākehā/NZ European

Samoan

Tongan

Fijian

Niuean

Cook Island

Other

If Māori - Iwi or tribe affiliation

Emergency Contact Information

We have this contact information for emergencies only

Is your emergency contact aware of this referral?

Yes

Emergency Contact Name

Relationship to you

Emergency Contact Phone

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referral Information

Supports Involved

GP/Doctor

Nurse Practitioner

Health Coach

Health Improvement Practitioner

Dietician

Are you currently experiencing any of the below? Please tick any/all that apply to you

Alcohol/Drug Dependence or Abuse

Anger management

Emotional regulation

Food management problems

Family conflict/harm

Fears

Grief/loss

Gender/Identity/Sexuality

Self harm

Lack of support/isolation

Lack of motivation

Learning difficulties/literacy

Nervous/anxious

Past abuse/trauma

Peer relationships

Suicidaility

Sadness

Self-esteem struggles/confidence

Worries

Withdrawn

Do you have any previous mental health history?

Yes

Any known mental health difficulties or symptoms

If yes, please specify

Brief history of food management problems, current or main concern(Required)

Appointments

Please note, initial appointments last up to one hour and run during office hours only.

Will you be bringing a support person to attend your appointment with you?

Yes

How would you like to be contacted to confirm your inital appointment

Text

Phone call

Consent

We are unable to accept this referral without consent to liase with your GP and we will submit a final summary report upon closure of this referral. We have a close liaison relationship with the South Island Eating Disorder Service, we require your consent to consult with them about your referral if applicable.

I understand and agree to the above conditions

Yes

I'm not sure