Please read and complete the following form.
The Referral will be assessed and we will respond as soon as possible.
Required fields are marked **

Starfish Clinic Referral Form This form is for both child and adult referrals. If a question is inappropriate, or you object to answering it, just leave it blank.
Referrer's Details
Date (dd/mm/yy):	dd/mm/yy**	Referrer's Name:	**
Agency Name if applicable:		Telephone:
Agency Address (if different to client's):		Fax:
		Email Address:
Does the client have a clinician they wish to see while at Starfish?	No Yes
If Yes, which clinician would they like to see:
Client's Personal Details
First Name:	**	Dob (dd/mm/yy):
Surname:	**	Gender:	Male Female Trans
Home Address:		Marital Status	Single Married De Facto Divorced
Telephone:
Client's children: Boys	Number 1 2 3 4 5 6 7	Boy age/s:
Client's children: Girls	Number 1 2 3 4 5 6 7	Girl age/s:
Benefit:	Sickness Unemployment DPB Invalid No Benefit Working
Ethnicity:	Pakeha Maori Pacific Islander Other
Iwi:(If NZ Maori)
Client's parent details
Father's Name		Age
Father's Occupation		Note
Mother's Name		Age
Mother's Occupation		Note
Client's main carer details if living with parent or other caregiver
Relationship		Street Address
First Name		Suburb
Last Name		City
Phone Number		Note
Main Problems
Please describe your main problems:
Previous Treatment Details
Previous treatment including Where, How long for and Year
Which service do you require from Starfish:	Psychiatrist Initial Assessment Psychologist Initial Assessment Court Report Family Therapy Cognitive Behavior Therapy Child Psychotherapy Adult Psychotherapy Group Therapy Forensic Assessment Second Opinion Expert Witness Consultation Supervision Other - give details	Service Details:
Legal
Any court appearances due?	No   Yes	What date and Where
Current (Include Supervision, Loss of licence, protection orders etc)
Other Agencies Involved
Name of agency/s
Client's school, college or workplace
Name:		Telephone:
Address:		Fax:
Is the client happy for us to contact their school, college or workplace if necessary?	Yes  No
Physical Health
Any allergies, current or previous illness or treatments
Does the client have any physical condition or disability? (If so please give details)
Client's General Practitioner
GP name:		Telephone:
Address:		Fax:
		Email Address:
Is the client happy for us to contact their GP if necessary?	Yes  No
Mental Health
Past and current contact with MHS, medications past and current:
Is there a recent Psychological report?	No   Yes	Send to us via:	Post Email Other
What do you hope to achieve at Starfish
Client's hopes and plans for the future
Funding We are an independent practice and we have to charge for the work we do. Please tick any relevant arrangements and give details.
Funding Arrangement:	Health Insurance DHB Funding CYFs Courts Taikura Trust* WINZ* Trust Fund Client/Family self funded Other - give details Taikura Trust and WINZ - by pre-arrangement with case manager	Funder Details:
IN ORDER TO SPEED UP THE ASSESSMENT PROCESS PLEASE MAKE SURE TO SEND US ANY REPORTS OR PRIOR ASSESSMENTS
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