Referring Someone Else – Te Hononga me te Pūtea Puka Whakawhiti

Your Way | Kia Roha provides disability support services to eligible people living within New Zealand. Please complete this form if you wish to refer someone to our Connections & Funding service e.g. a patient, someone you’re working with. Please note that you must have the person’s permission to make a referral on their behalf, or that of a parent / guardian if the child or young person referred is under 18 years old. There are eight sections.

Disabled people and parents of disabled children can refer using Your Way | Kia Roha Connections & Funding Self-referral Form.

If you need assistance with the form or have questions about our referral process, please contact our team on 0800 758 700 or email referrals@yourwaykiaroha.nz

If it’s the first time we have received a referral from you, we will also need:

• The referred person’s GP / medical specialist to complete the Confirmation of Disability Form which can be downloaded here Make a referral – Your Way | Kia Roha (yourwaykiaroha.nz)

• Specialist reports if the person has an intellectual disability or Autism Spectrum Disorder.

Step 1 of 8

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Section 1 - About the person being referred

Name(Required)

First name / s Surname

Title

Mr / Mrs / Ms / Miss / Master / etc.

Preferred name

To be used when we contact you

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Telephone or mobile number(Required)

Email address

I prefer that you contact me by email / phone / text(Required)

EmailPhoneText

Date of Birth(Required)

DD / MM / YYYY

Gender(Required)

FemaleMaleNon-BinaryTransgender ManTransgender WomanAgenderPrefer not to sayOther

Other

Pronoun

She / He / They / etc.

Residency Status(Required)

NZ CitizenNZ ResidentNon-NZ Resident

Date of Residency

Residency information / visitor status

Please provide information on your residency / visitor status

Ethnicity(Required)

MāoriNZ EuropeanEuropeanAsianPāsifikaOther

Iwi / Hapū

Island / Islands

Enter ethnicity

First language - if not English

Interpreter required(Required)

Yes

No

Cultural support required(Required)

No

Yes, I will bring someone

Yes, please provide

Please explain support required(Required)

Are there communication needs that Your Way | Kia Roha should be aware of when working with the person referred(Required)

No

Yes

NZSL

Other

Please tell us about your needs

Section 2 - Medical Information

Doctor / GP name

Doctor / Medical Centre address

Doctor / Medical Centre telephone number(Required)

National Health Index (NHI) number, if known

Please attach Confirmation of Diagnosis Form

Accepted file types: pdf, docx, Max. file size: 100 MB.

The Confirmation of Diagnosis Form can be downloaded from the referral page of our website. It must be completed by a doctor or specialist.

Section 3 - Disability Information

Disability name / type

Other medical / health issues (if any)

Reasons for referral

Supports / services the person would like(Required)

Information about services and supports

Connection with services and support

Development of a Living Well Plan with me

Unsure

Select all that apply

The services / supports I need are(Required)

Urgent (required within two days)Semi-urgent (required within one week)Non-urgent

Section 4 - Additional Information

Safety, hazards or other sensitive issues Your Way | Kia Roha should be aware of when working with the person referred

Any other important information Your Way | Kia Roha should know about the person referred

NoYes

Please provide more information

Section 5 - Alternative Contact

This section is optional unless you are referring a child or young person under 18 years, then please include contact details for the parent or guardian.

Name

First name / s Surname

Contact phone number

Email address

Relationship to the person referred

Section 6 - Referrer's contact details

Name(Required)

First name / s Surname

Contact phone number(Required)

Email address

Relationship to the person referred(Required)

Section 7 - Consent and Privacy Statement

Please select "I Agree" for each field to show consent

The person referred, or their guardian or parent (if under 18 years), has given me permission to provide all information contained on this Referral so Your Way | Kia Roha can assess her / his eligibility for services.(Required)

I Agree

I understand that the information I have provided will be shared with relevant Your Way | Kia Roha employees, the Ministry of Social Development and other professionals to assess the person’s eligibility for services.(Required)

I Agree

I understand that both the person referred and I may be contacted to verify my right to provide information and to obtain additional information required to assist in the assessment process.(Required)

I Agree

The person referred and I understand information such as ethnicity and age may be collected for statistical purposes and shared with the Ministry as part of Your Way | Kia Roha reporting.(Required)

I Agree

I understand the person referred can ask for copies of all the information I have provided and correct any information that is wrong.(Required)

I Agree

Section 8 - Signatory

You have now reached the end of the document. Please sign and date below.

How would you like to sign this referral?(Required)

Digital Signature

Text Input

Signature (please type in your name to sign)(Required)

Signature

Name of parent / guardian completing (if on behalf of a child)

Thank you for your referral. We will contact you within seven working days if we require more information or to let you know the outcome of your referral. If you haven’t heard from us within seven working days, please email us at referrals@yourwaykiaroha.nz or phone us on 0800 758 700.