Please Note: This is an Electronic Referral, designed to be completed as a WORD Document, once completed please SAVE and attach in an email and send to .

If you require a paper version to fax or post, please let us know.

Persons Details:
Surname / NHI Number
First Names / Date of Birth
Also known as / Gender
Address / Phone
Suburb / Mobile
City/Post Code / Fax/Email
Doctor / Doctor Phone
Ethnicity / NZ European Maori – Iwi
Other: / NZ Permanent Resident: Yes No
Interpreter Required: Yes No / Type:
Community Service Card: Yes No / CSC Number: / Expiry:
Living Situation: Alone With Spouse/Partner With Family Other:
Best way and time to contact person:
Referrer:
Name / Phone & Extension
Organisation / Relationship to person
Postal Address / Email (MUST be supplied)
Date of Referral / Signature
Consent:
Is the person aware of the purpose of this referral? / Yes No
Does the person consent to this referral? / Yes No
Who consents for the person if they are unable to? (Please provide documentation to confirm this role).
Additional Guardian Welfare Guardian Enacted EPOA Parent of child (<17yrs)
Other: Name & contact details
Does the person consent for Enable New Zealand NASC to gather further information to support the referral? Yes No If not please explain:
Primary Carer / Legal Representative / Alternative Contact:
Name / Date of Birth
Address / Phone
Mobile/Email
Relationship to person:
Diagnosis & Disability – Specialist Reports MUST be attached to support this Referral:
What is the persons primary diagnosis?
What is the persons secondary diagnosis?
Is the referral a result of an accident? Yes No / Is ACC funded support in place? Yes No
Are CYFS involved? Yes No / Orders section 101 section 141 other
Events leading to referral?
Functional Impairment likely to last longer than 6 months: Physical Sensory Intellectual
Impacts on: personal care home management carer stress
Urgent- please explain why?
Any Risks / Alerts you are aware of?
Hospital Discharge Details: ( For Hospital use only – Please submit with referral)
Hospital Ward: / Proposed discharge date:
Proposed discharge address
DHB short term services in place on discharge? / Yes No
Details of services/follow up planned?
Can person go home prior to NASC services? / Yes No
Comments:
Please add any other information that can assist us – all information is confidential:
e.g. history relevant to referral, any concerns, mental health status, other agencies involved:

Thank you for your referral.

Please ensure your email address is included on this Referral as our response will be sent by email to advise you of the outcomeand the next steps.

Please note we will not process your Referral if supporting documentation is not provided.

For Enable New Zealand NASC Staff Only:
Eligible: DSS NA SC / Decline: LTS-CHC ACC MH PH CMI Age Related
Urgency: 24hrs 5 days 10 days 20 days
Rationale & Recommendation:
Date: / Signature:

EMAIL:

PHONE: 06 353 5899, CALLFREE 0800 362 253

ADDRESS: P O Box 4547, Palmerston North 4442