Adult Therapy Referral

The following information is required to process your referral and may be used in a non-identifiable way by START for statistical purposes

Referrer's Details

Please complete the details for the person making this referral.

Please complete all required * fields

Referrer: First Name

Last Name

Referrer's Phone/Mobile

Referrer's Email

Is this a Self-Referral (are you completing this referral for yourself)?

Yes

Relationship to person being referred

Do you consent to being contacted by START regarding this referral?

Yes

Details of Referred Adult

Please complete all required * fields

First Name

Middle Name

Last Name

Preferred Name

Please enter the name you prefer to use if different from that above

Date of birth

To quickly select your year of birth, click on the year (e.g. 2024) and type your year of birth

Address:

Address Line 1

Address Line 2

Suburb

City

Postcode

Country

Phone/Mobile

Ethnicity

Does the person identify as Māori?

Yes

Iwi

How does the person describe their gender?

Man/Male

Woman/Female

Non-binary

Prefer not to say

Another term, let me type ...

Text Input

What are their preferred gender pronouns?

He/him/his

She/her/hers

Ze/hir/hirs

They/them/their

Something else, let me type ...

Text Input

Emergency Contact Details

Emergency Contact

Emergency Contact Phone/Mobile

Emergency Contact Address:

Address Line 1

Address Line 2

Suburb

City

Postcode

Country

Required Information

Please complete all required fields along with any other fields that apply

Living situation

How did you hear about START?

Have you previously been a client with START?

Yes

Previous therapy provider

Relationship to the person who harmed you

Are you still in contact with the person who harmed you?

Yes

Do you have a Protection Order in place regarding:

Yourself?

Yes

Your children?

Yes

Who is the named party in the Protection Order?

Is there anyone else that you have safety concerns about for yourself/your child?

Yes

Others of Concern

Are there any safety plans START should be aware of, or ways we can assist you with keeping safe?

Are there any times or days that you may be unable to attend therapy?

We operate during business hours. Therapy appointments will be offered for the same day and time each week. You are expected to attend each week. If you have restricted availability it will result in a longer wait time.

Would you like to receive appointment reminders?

Yes

Are we able to leave telephone messages for you?

Yes

Are there any times or days that you may be unable to attend therapy?

Doctor's name and Medical Centre contact details:

Where appropriate, do you consent to a clinical staff member contacting your doctor?

This will be discussed with you first, wherever possible

Yes

Have you previously had an ACC Sensitive Claim?

Yes

Where applicable, do you consent to a staff member contacting ACC regarding your previous claim?

Yes

Please include your ACC claim number: (if known)

Have you had contact with mental health services?

Yes, currently

Yes, previously

Mental Health Services Involved

Where appropriate, do you consent to a clinical staff member speaking with mental health services?

This will be discussed with you first, wherever possible

Yes

If you heard about us through the Sexual Violence service at Aviva, do you consent to us speaking with them relating to this referral?

Yes

Do you have any other services currently involved?

(e.g. Health, Police, Community services, Iwi services, Alcohol & Drug services, Oranga Tamariki, Probation etc.)

Yes

Please let us know who else is involved:

Where appropriate, please tell us if you would consent to a clinical staff member contacting any of the above identified services and if so, which service(s)?

This will also be discussed with you first, wherever possible

I consent to START processing this referral and collecting any necessary information

Date