AHS Application Form

Client Referral Form for Amitabha Hospice Service, Auckland, NZ

Please ensure that your client referral meets our service criteria:

Our service can be engaged by doctors, nurses, social workers, heath agencies and family members who see a need for non-medical holistic support companionship of an adult with a debilitating or life limiting health condition or a terminal prognosis.

Please note: With the exception of mild Dementia we do not accept referrals for people with a diagnosed mental illness that falls outside the scope of our volunteer training

Name of Referrer

Date of Referral

Referrer's Agency

Referrer's Phone # (+ extn)

Referrer's Email

Client's Name

Client's Phone #

Client's Address

Date of Birth

Primary Language

Speaks English?

Gender

Lives With? (alone, daughter, husband etc)

Primary Carer

Carer's Relationship to Client

Carer's Home/WorkPhone #

Carer's Mobile #

Client's NHI Number

Name of Doctor

Doctor's or Medical Practice Phone #

Client's Relevant Mental and Physical Medical History

Reason for Referral (particular needs and problems e.g. isolation, language, mobility)

Special Concerns (family members, dangers, poverty, etc)?