FM.R4.28
6/18
Community Health 4 Kids Freephone: 0800 935 554
REFERRAL Public Health Nurse (PHN) Service Community Health 4 Kids (CH4K)
Please tick who referral is for: PHN
AGROHVFHQW PHN
PUHVFKRRO PHN
Child’s Surname (s) DOB:
Ear Nurse
VHT
First Name(s) Gender:
NHI:
Ethnicity:
Address: Parent/Caregivers Contact number(s)
Home:
Mobile:
Email address: Has referral been discussed with caregiver? If No state why
Yes
No
Has CH4K service leaflet been provided to caregiver? <HV 1R Has the caregiver agreed to the referral? <HV 1R School/ preschool
Classroom
Referrer name
Agency
Referrers contact (number and email) Date of referral Are you aware if child /family are engaged with other services (please tick) GP
RTLB
Counselling
SENCO
3D
Family works
SWIS
Oranga Tamariki (formerly CYF) Adult MH
Paediatrics
MiCAMHS
Strengthening Families
Tamariki Ora/ Well child
STAND
Plunket
Te Whanau Kotahi
Voyagers
CDU
Family Start
OTHER (please state)
Reason for referral and other relevant information
Expected outcomes of referral to CH4K
Date referral received by PHN If this button doesn't work, press the envelope icon at the top of the page to send
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EMAIL to Health Nurse (PHN) Service EMAIL toPublic phn.referral@bopdhb.govt.nz
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