Personal Focus Form

Section 1

Personal Focus is available to persons with lived experience of Mental Illness & between the age of 16 & 65. We are required by our funders to gather the following information for statistical purposes & to confirm eligibility to attend Personal Focus.
Missing information & documentation will slow down the referral process & your ability to attend the service.

First Name *

Last Name *

Date of birth *

Street Address *

Phone number *

Gender *
MaleFemaleGender DiverseOther - Please specify if you would like to

Ethnicity

WINZ Number

NHI Number

Email address

What is your Mental Health Diagnosis?
(Our administrator will ask you for this if you do not wish to add it online. It is compulsory to disclose this information to confirm your eligibility to attend the service)

Describe your citizenship or residence status *
New Zealand Citizen (NZL)New Zealand Permanent Resident (NZP)Other

Which of these documents can you provide?
Care PlanRisk Management PlanWellness Recovery Action Plan (WRAP)Risk AssessmentEarly Warning SignsI don't have access to any of these (A facilitator will support you to develop a Self-care plan)

Reason for referral: *
Akiaki Ora - Individual support for pre-employment, study, or involvement in your communityWhiti Ora - Group programmes

Please list the group/s you would like to attend or the type of group if you have not decided. You can view our group timetables on the website.

I give permission for Ember to approach my clinical provider/general practitioner/support worker for further information if necessary. This information will be kept confidential along with other personal records, as required by the Health Information Privacy Code (1993).*

Section 2

Additional Information *

Do you have further significant information we should be aware of? E.g. Medical conditions such as Diabetes, Epilepsy etc.
YesNo

Is there anything else you feel is important for us to know?