Enliven Referral Form

Referral Date

First Name

Last Name

Preferred Name

NHI

Date of Birth

Phone Number

Email Address

Street Address *

Post Code

Suburb

City

Country

Medical Centre Name

Doctor / Medical Centre Phone

Doctor's Name

First Name

Last Name

Enliven Services

Please tick required services below and specify the best location (if applicable)

Non-day programmes

Counselling (Christchurch East, Ashburton)

Social Work (Christchurch East, Ashburton, Rangiora, Hurunui)

Falls Prevention (Rangiora, Kaiapoi, Amberley)

Kaiāwhina (Christchurch, North Canterbury)

Pastoral Care (East Christchurch)

Day Programmes

Harakeke (Riccarton, Linwood, Nelson)

Tōtara (Riccarton, Rangiora, Nelson, Marlborough)

HomeShare (Ashburton, Selwyn, Christchurch, Hurunui, Rangiora, Marlborough, West Coast)

Community Respite Care (West Coast)

Please provide reason for referral

Specific needs/general comments:

Social Worker / Key Worker

HomeCare Provider

Other

Subsidies Approved

Day Care

Carer Support

Risk Factors

Falls

Allergies

Mood / Emotional Status

Nutrition

Environment

Anything not on our list?

Cognition / Dementia

Level of functioning

Behavioural concerns

Sensory & Mobility

Sight

Good

Impaired

Spectacles

Hearing

Good

Impaired

Wears Aids

Mobility

Independent

Assistance

Mobility Aids

Toileting

Independent

Reminders

Assistance

Comments

Specialist / Support Services involved

Health Issues

Additional Information

Preferred attendance days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred attendance times

I give my consent for the information provided in this referral form to be passed on to the appropriate staff *

Enliven - Referral Form

Enliven – Presbyterian Support upper South Island

Enliven Services

Non-day programmes

Day Programmes

Cognition / Dementia

Sensory & Mobility