3D Coordination
G.P. Referral form
For G.P. use only
To: 3D Coordination
3D Coordination Practice:
Name:
Family Name:
First name:
Country of Birth
NZ Citizen?
NHI:
DOB:
Family Name:
First Name:
G.P. Details Also known as:
Child details Residency Status
Parent/NOK/ Carer details:
NZ Resident? Gender: Relationship to child:
Address:
Phone: Email Name School/EEC Presenting concerns and relevant examination findings: (vision, hearing) Past Medical History: (include relevant antenatal and birth details)
Mob:
Parent agrees to 3D emailing questionnaires to school?
Medication Allergies Immunisations:
Relevant Family History Social History:
Relevant Developmental History: Feedback will be given on the referral pathway. Please send to 3D Coordination: Healthlink EDI: kaitiaki Email 3D@kaitiakiservices.co.nz Fax 571 0154
Date:_______________ 3D Coordination Kaitiaki Services 47 Fraser Street Tauranga South TAURANGA 3112
G.P. Signature:_________________________________________________________ Email: Phone: Fax: Mob:
3D@kaitiakiservices.co.nz 07 571 0144 07 571 0154 027 207 1914
3D Coordination
3D Coordination Is a referral and information service for children with Developmental, Attention, or Behaviour Needs Role: To improve access to services for children with possible Autism Spectrum Disorder, Attention Deficit/Hyperactivity Disorder or Intellectual Disability, by streamlining the referral process, facilitating community supports and advocating for services as necessary. Criteria for enrolment to 3D Coordination: The child or young person: Is 14 years of age or younger. Is resident in the Western Bay of Plenty (bounded by Waihi Beach in the North, Otamarakau in the East and lower Kaimai ranges in the South). Presents with behaviour/development issues suggestive of Autism Spectrum Disorder, Attention Deficit/Hyperactivity Disorder or Intellectual Disability. May have associated disruptive behaviours. Requires a medical check-up and referral from a G.P. The child does not currently access services from: Maternal, Infant and Child Adolescent and Mental Health Services – MICAMHS. Ministry of Education ORRS. Ministry of Education, Learning Support
Who can enrol child into service? Parents can enrol to get the 3D assessment process started. Educators, health professionals and community agencies can enrol a child with the parents’ permission. Contact will be made with the family. The family may need to get a G.P. referral following a medical check-up to complete the referral process. For further information, or queries, parent information brochures, or enrolment forms please contact
Jan Glover 3D Coordinator 3D Coordination Kaitiaki Services 47 Fraser Street Tauranga South TAURANGA 3112
Email: Phone: Fax: Mob:
3D@kaitiakiservices.co.nz 07 571 0144 07 571 0154 027 207 1914