Active Families All Health Professionals Referral Form ACTIVE FAMILIES/TEENS REFERRAL FORM ALL HEALTH PROFESSIONALS WEST AUCKLAND, NORTH SHORE AND RODNEY 1. Please note all fields are compulsory 2. Notify your patient that a Family Support Worker will be in touch within 10 working days of receiving the referral 3. Contact Harbour Sport if you have any questions on 09 415 4657 Section 1 – Patient Details (All Fields Compulsory*) First Name * : Surname * : Gender * : MaleFemale Date of Birth * : Ethnicity * : Street Address * : Suburb * : Postcode * : Phone * : Home PhoneMobile PhoneWork Phone Section 2 – Medical Conditions (All Fields Compulsory*) BMI * : Patient Medical Conditions (Please list all medical conditions, including weight issues/stress) * : Diabetes * : Pre-diabetic (HbA1c 41-49mmol)T1T2Not Applicable Other relevant information * : File Attachment (Only add if required. If multiple files is needed, please zip into one folder first.) Section 3 – Referrer Information (All Fields Compulsory*) Referrer Health Professional * : Phone * : Extn * : Clinic/Agency Referred From * : Postal Address * : Date * : By ticking this, I confirm that I have explained the Active Families/Teens process and the patient has consented for their details to be forwarded to HARBOUR SPORT Active Families/Teens who will provide them with support and advice.