SELF REFERRAL

SELF REFERRAL FORM

To refer someone with dementia to PACIFIC DEMENTIA MĀNGALO
You can fill out the online form and submit it electronicaly – or you can use the downloadable PDF PACIFIC DEMENTIAL MĀNGALO SELF-REFERRAL FORM Please print it off, fill it in and email it to us.

Email: dementia@athwa.org.nz
Postal Address: Aotearoa Tongan Health Workers Association INC. – ‘Ākiheuho | 25 Princes Street, Otahuhu | PO Box 22336, Otahuhu, Auckland1640, New Zealand

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FULL NAME *

RELATIONSHIP TO PERSON WITH DEMENTIA *

DATE (Today) *

PHONE (Home / Work / Mobile) *

EMAIL *

SERVICE OFFERED *

• INFORMATION ON DEMENTIA
• PHONE CONSULTATIONS
• KEYWORKER SUPPORT / NAVIGATION
• SUPPORT GROUPS FOR CARERS
• EDUCATION COURSES FOR CARERS / FAMILIES
• ACTIVITY GROUPS FOR PERSON WITH MILD TO MODERATE DEMENTIA
• OTHER (Please specify on next textbox)

Please indicate your interest

OTHER SERVICE

Please specify

PERSON LIVING WITH DEMENTIA *

First

Last

PREFERRED NAME (Person living with dementia)

DATE OF BIRTH (Person living with dementia) *

ADDRESS & POST CODE *

Person living with dementia

PHONE (Home / Work / Mobile) *

Person living with dementia

GENDER *

• MALE
• FEMALE

Person living with dementia

ETHNICITY *

Person living with dementia

NHI NUMBER *

Person living with dementia

DIAGNOSIS (Type of dementia) *

RECENT COGNITIVE TEST RESULTS

Please enter the Date/ Test/ Score/ Other: Specify

CARE DETAILS (We provide support services to carers) *

First

Last

ETHNICITY *

Care Details

DATE OF BIRTH *

Care Details

ADDRESS & POST CODE *

Care Details

RELATIONSHIP TO PERSON WITH DEMENTIA *

Care Details

EMAIL

Care Details

PHONE (Home / Work / Mobile) *

Care Details

OTHER RELEVANT INFORMATION

CONSENT GIVEN *

• YES
• NO

Submit