REFERRAL FORM

GRACE FOUNDATION Rehabilitation & Reintegration Referral Form

He Tangata
Referral Type*

RemandParoleSentencingMSDSocial HousingHomelessIn communityOther
Full Name*

First NameMiddle NameLast Name
Nickname
Birth Date*

DayMonthYear
Gender*

TaneWahineOther
PRN: *
NHI:
Are you a Work & Income (WINZ) client?*

YesNoI don't know
What is your WINZ client number
Are you a NZ resident?*

YesNoOther
Ethnicity*
Other:
Iwi
Other:
Whakapapa (Region of Origin)
Current Accommodation Status
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Housing status*
Other
If you are in prison:
Are you connected to any social housing?*

YesNo
If yes, you or your partner?
Enquirer 1 Details

Lawyers/Case Manager/Other Organisations
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email*
example@example.com
Referral Organisation*

DHBCorrectionsLawyerMSDOranga TamarikiRelativeSelf-ReferralWork & Income NZBail Support ServicesOther
Name of Organisation:*
e.g. Auckland DHB, NRCF, New Lynn SC
Enquirer's Role*
Other
Enquirer 2 Details

Lawyers/Case Manager/Other Organisations
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email*
example@example.com
Referral Organisation*

DHBCorrectionsLawyerMSDOranga TamarikiRelativeSelf-ReferralWork & Income NZBail Support ServicesOther
Name of Organisation:*
e.g. Auckland DHB, NRCF, New Lynn SC
Enquirer's Role*
Other
Next Of Kin
Full Name

First NameLast Name
Address

Street Address

City

Postal / Zip CodeCountry
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Email
example@example.com
Referrals' Details / History
Charges*
Other Charges
Time In Remand
Gang Affiliations (Grace Foundation Take Gang Members)*
Reason For Referral*
PAROLE applicants

If you are not applying for parole, please leave this blank
Total Sentence
Time Served To Date
Sentence End Date

DayMonthYear
Next Parole Hearing Date
Number Parole Hearing

1st2nd3rd4th5th6th7thOther
Education
Any Education
Highest Form of Education

Incomplete SchoolingYear 11Year 12Year 13CertificateDiplomaUniversityTradeOther
Any Qualifications/Trades
Identification
Student ID:
Drivers License *
Drivers License Number (if you know it)
Passport Number
Medical Information
Are you a smoker?*

YesNo
Do you currently struggle with Mental Health?*

YesNo
If yes, what is your diagnosis?
Mental Health Scale*
Do you have any medical conditions?*

YesNo
If yes, what is your diagnosis?
Do you have any physical disabilities?*

YesNo
If yes, describe your disability
Do you take any medications?*

YesNoOther
If yes, what medications?
Addictions
Please tick the applicable boxes*

AlcoholCigarettesCocaineCrimeGamblingGBLMarijuanaMDMAMethamphetaminePornographySexSyntheticsVapingViolenceOther
Risks/Concerns/Needs
Safety and Risk Issues*
Other Comments
Grace Foundation Provide
1. Furnished room

2. Food supplies;        class meals, communal grocery items

3. Transport:               Winz, doctor, probation, class, church, programs, excursions, court (within Auckland region)

4. Day Class:               'Soulutionz' 3 Phase Program/Activities

Phase 1: 12-16 weeks

Phase 2: 12-16 weeks

Phase 3: 12-16 weeks
Accommodation/Rehabilitation/Re-integration Costs
Total Admission costs for accommodation and wrap around services:

Grace Foundation Auckland (Mens):

Linen Kit: $200.00 (Grant)

Advance:                   $1000.00 (2 weeks rent).

Rent per week:           $500.00

TOTAL:                     $1,200.00  (Total Admission Costs)

Grace Foundation Auckland (Women):

Linen Kit: $100.00 (Grant)

Advance: $1000.00 (2 weeks rent)

Rent per week:           $500.00.

TOTAL:                      $1,100.00  (Total Admission Costs)

Grace Foundation Youth:

Linen Kit: $150.00

Advance: $1000.00 (2 weeks rent)

Rent per week: $500.00

TOTAL: $1150.00 (Total Admission Costs)

Note:   Total admission costs will be covered by 'Work & Income NZ' (WINZ), we have advocates who will arrange this for all incoming residents.
Grace Foundation Charitable Trust (Auckland

Email: admin@gracefoundation.co.nz
Date Referral Form Completed

DayMonthYearHourMinutesAM/PM Option
Should be Empty:

GRACE FOUNDATION Rehabilitation & Reintegration Referral Form

Current Accommodation Status

Enquirer 1 Details

Enquirer 2 Details

Next Of Kin

Referrals' Details / History

PAROLE applicants

Education

Identification

Medical Information

Addictions

Risks/Concerns/Needs

Grace Foundation Provide

Accommodation/Rehabilitation/Re-integration Costs

Grace Foundation Charitable Trust (Auckland