2024 NON Subsidy - Client Stats Sheet - NFNZ 
If your client is receiving a subsidy please fill in the form: 2024 Subsidy - Client Stats Sheet-NFNZ, Copy and paste this link into your browser:    https://forms.gle/eDdotAC4BJ76XT448



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Email *
Educator Name   *
Select your name from this list
Client Number
So that you know what client this is in reference to in your records
Date client was seen *
The date you saw this client
MM
/
DD
/
YYYY
Who Attended this Appointment? *
Method Chosen *
What classification was this client? *
Choose One Only Please
If you have made a 12month follow up call, what was the outcome. Check multiple boxes if required.
If pregnancy is achieved, was it a live birth?
Clear selection
What age bracket was the female? *
If same sex couple please note the age of the female wishing to conceive
What age bracket was the male/partner?
Leave blank if no male/partner attended
What Ethnicity was the female?
Tick all that apply to female
What Ethnicity was the male/partner attending?
Leave blank if no partner attended
Where did the clients hear about NFNZ or who referred them?
Choose as many as apply to anyone present
Client Region *
Where your client is from, not the area of the educator (ie. you may be in Auckland but your client may be via distance education from Dunedin (Otago Region) Please use maps below as a guide, or use your browser to confirm their Region.
North Island Regions
South Island Regions
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