Heart Collective Triage Form
The purpose of this form is to gather enough information about you so that we can assess your needs and identify available funding. We will triage and get back to you usually within three business days. Please note our Administration hours are Monday to Wednesday, 9:00am - 2:30pm.
If you are completing this referral for yourseIf please type SELF below. If this referral is being made on behalf of the client, please provide your name and relationship to the client and confirm the client is aware that this referral has been made. *
Client Name *
Date of Birth *
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DD
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Ethnicity *
Gender *
Phone number *
Email address *
Residential Address *
Registered Medical Practice and NHI (if known) *
Please provide reason for seeking help at this time. Supply as much information as you can about the reason for this referral. Lack of information is the most common thing for declining or holding up the request. *
Have you had previous ACC engagement for a sensitive claim? (If you are not sure that you meet the criteria for an ACC Sensitive Claim please refer to the information under ACC on this page https://www.heartcollective.co.nz/fees *
ACC sensitive Claim # (if known)
Preference for male or female therapist *
Have you ever been involved with Mental Health services or the crisis team? If Yes, please provide details including diagnosis and current medications. *
Do you currently have any Drug and Alcohol abuse problems? If Yes please provide details *
Are you currently taking any prescribed medications or natural remedies not listed above? If yes, please provide details. *
How did you hear about us?
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