Ngā Tekau Alcohol and Other Drugs Service Form

Referral to Kaupapa Māori AOD Service

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Name *

First

Last

Address *

Phone *

Emergency Contact (Name) *

Emergency Contact (Phone) *

Ethnicity *

Gender

Iwi/Hapū

DOB *

NHI Number

Dependents

Referral (only fill in if not self-referral)

Referred by

Organisation

Phone

Address

Referrers role

Level of contact

Emergency Contact Details

First Name

Surname

Phone

Addiction issues

How long has use been problematic?

Any other professional / Agencies currently involved?

Other relevant information

I hereby consent to the above information being made available to Ngā Tekau AOD Service *

Agree

Date

CONTACT DETAILS

Phone: 04 473 2502

Freephone: 0508 445 645

health@tekau.maori.nz

24d Marine Parade
Hīkoikoi
Petone
PO Box 39294
Lower Hutt 5045

HĪKOIKOI MANAGEMENT LIMITED EXECUTIVE OFFICE

Phone: 04 473 2502
Freephone: 0508 445 645
info@tekau.maori.nz

24d Marine Parade
Hīkoikoi
Petone
PO Box 39294
Lower Hutt 5045

WELLINGTON OFFICE

Phone: 04 801 7227

Level 1, Te Raukura (Te Wharewaka)
2 Taranaki Street
Wellington
PO Box 39294
Lower Hutt 5045

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