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If you, or someone you care for, is interested in accessing these supports, complete the form below
Who is this for?
It's for myself
I'm making a service referal
It's for a family member or friend
Does this person know that you are referring them to our services?
- None -
Yes
No
Please speak to the person you wish to refer and notify them before referring.
VC Clinic Referral Form
VC Clinic Referring Myself Form
VC Clinic Referring Family or Friend Form
Referrer Information
Name
Organization (if applicable)
Role/Relationship to client
Relationship to client
Phone Number
Email Address
Client Information
Full Name
Date of Birth
NHI Number (if known)
Gender
Trans / Non-Bnary / Another Gender
- None -
Yes
No
Not Sure
Ethinicity / Cultural Identity
Preferred Language
Interpreter Required?
Address
Phone Number
Email Address (if any)
Preferred Contact Method
Is it safe to contact client directly?
Emergency Contact (Name & Number)
GP / Primary Healthcare Provider
Reason for Referral
General Health Check-Up
Sexual Health Check-Up
Psychologist / Talanoa Session
Pacific Rainbow+ Youth Skills Group
Other (please specify):
Enter other…
Additional details (symptoms, concerns, or context):
Service Specifics
Urgency of Referral
Routine
Within 1 week
Immediate
Services Requested
STI Checks
Contraception Advice
Counselling / Psychologist Session
Health Checks
Wellbeing Support
Other:
Enter other…
Services Requested
STI Checks
Contraception Advice
Counselling / Psychologist Session
Health Checks
Wellbeing Support
Pacific Rainbow+ Youth Skills Group (Sei Lelei)
Other:
Enter other…
Services Requested
STI Checks
Contraception Advice
Counselling / Psychologist Session
Health Checks
Wellbeing Support
Pacific Rainbow+ Youth Skills Group (Sei Lelei)
Other:
Enter other…
Has the client previously engaged with Village Collective?
Yes
No
Not Sure
How did you hear about us?
How did you hear about us?
- None -
Family/Friends
Social Media
Social Media Influencer
Online Advertising
Social Worker or Youth Worker
Mental Health Professional
Doctor / GP
Community Event / Outreach
Physical Advertisement
Other…
Enter other…
Consent & Privacy
I confirm the client has provided consent for this referral.
I understand this information will be kept confidential and used only for the purpose of referral.
Submit
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