080092976468

Waypoint Introduction – Short Form

Please fill in the details below.

Referrers Full Name

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Referrers Organisation and Title

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Referrers Email Address

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Referrers Mobile Number

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Client Information: Name

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Last Name

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Preferred Name & Pronoun

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Date of Birth

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NHI (if available)

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Home Address

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Contact Number

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Email

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Ethnicity

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Emergency Contact: Name, Mobile number, Relationship?

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GP Details (if available)

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Does the Young Person Consent to Waypoint having their details?

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Does the Young Person know we will contact them directly?

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Do you already have Waypoint Services in mind for the Young Person? Visit our website for a list of the services we provide. See 'How we can help' button below this form.

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About your Young Person: i.e, 5 P’s: Predisposing, Precipitating, Perpetuating, Protective and Presenting

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Current and immediate risk factors

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Address

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How we can help

Get in touch

askme@waypoint.org.nz

0800 WAYPOINT
0800 9297 6468
Hours
Monday to Friday - 8:30am - 4:30pm