Referral Intake Form

Referral Intake Form Template for New Zealand

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Key Requirements PROMPT example:

"I need a Referral Intake Form for our mental health practice in Auckland that includes specific sections for cultural support requirements, particularly for Māori and Pacific Islander clients, with integrated privacy notices compliant with the latest NZ healthcare regulations."

Document background

The Referral Intake Form serves as a standardized document for healthcare providers in New Zealand to manage patient referrals effectively and securely. This document is essential when transferring patient care between different healthcare services or specialists, ensuring all relevant medical information and patient details are properly captured and communicated. The form is designed to comply with New Zealand healthcare regulations, including the Privacy Act 2020 and Health Information Privacy Code 2020, while facilitating efficient service delivery. It includes sections for patient demographics, medical history, referral reasons, risk assessments, and necessary consents, with optional components that can be adapted based on specific service requirements or patient needs.

Suggested Sections

1. Client/Patient Information: Basic personal details including full name, date of birth, contact information, and NHI number

2. Emergency Contact Details: Name, relationship, and contact information for emergency contact person

3. Referrer Information: Details of the referring professional or organization, including contact information and professional registration number

4. Primary Healthcare Provider: Details of the client's regular GP or primary healthcare provider

5. Reason for Referral: Primary presenting issues and specific concerns necessitating the referral

6. Current Medications: List of current medications, dosages, and prescribing doctors

7. Relevant Medical History: Brief overview of pertinent medical history related to the referral

8. Risk Assessment: Basic assessment of any immediate risks or safety concerns

9. Privacy Statement: Declaration regarding information handling and privacy in accordance with the Privacy Act 2020

10. Consent: Client consent for referral and information sharing

Optional Sections

1. Cultural Considerations: Section for capturing cultural needs and preferences, particularly relevant for Māori and Pacific Islander clients

2. Interpreter Requirements: Details of language assistance needs, used when working with non-English speaking clients

3. ACC Information: Specific section for accident-related referrals requiring ACC details

4. Mental Health History: Additional section for mental health-specific referrals

5. Disability Support Requirements: Section for capturing specific support needs for clients with disabilities

6. Previous Service Engagement: History of engagement with similar or related services, useful for complex cases

7. Funding Stream: Information about funding sources and eligibility, used when multiple funding options are available

Suggested Schedules

1. Consent Forms: Standard consent forms for information sharing and treatment

2. Privacy Statement: Detailed privacy policy and information handling procedures

3. Service Criteria Checklist: Checklist to confirm eligibility for specific services

4. Risk Assessment Tool: Standardized risk assessment form if required for specific services

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Mental Health

Social Services

Disability Services

Rehabilitation Services

Allied Health

Primary Care

Specialist Medical Services

Community Health

Aged Care

Relevant Teams

Reception

Administration

Clinical Operations

Quality Assurance

Patient Services

Medical Records

Compliance

Clinical Governance

Service Coordination

Intake Processing

Relevant Roles

General Practitioner

Medical Specialist

Practice Manager

Healthcare Administrator

Nurse Practitioner

Clinical Coordinator

Referral Coordinator

Allied Health Professional

Mental Health Professional

Social Worker

Case Manager

Quality Assurance Manager

Privacy Officer

Healthcare Service Manager

Intake Coordinator

Clinical Director

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Simple Intake Form

A New Zealand-compliant intake form for collecting and managing client information, structured according to NZ privacy laws and business requirements.

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Let's create your Referral Intake Form

Authors

Alex Denne

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