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Unite against COVID-19

Workwise is open, with hygiene protocols and contact tracing at our offices. If you have a runny nose, a sore throat or a cough, please do not come in – get tested and self-isolate until you are cleared.

Visit www.COVID19.govt.nz for official information

Client details
First names:*	Gender: MF
Last name:*	Date of birth:*
Phone number:*	Country of birth:*
Mobile:	New Zealand resident: YesNo
Email:	Ethnicity: NZ European/PakehaEuropeanMaoriPacific IslanderOther Please specify: Please specify:
Region:*
Postal address:
Alternative contact details:



Health / benefit details
NHI number:	Benefit type: Supported living paymentSole parent supportJob seeker supportOther
Primary diagnosis:

Clinical support person:
Postal address:
Phone number:
Email:

Work & Income number:
Work & Income case manager details
Name:
Email:
Phone number:
Work & Income service centre:

I (the client), * give consent for any referring agency and Workwise to share information about me. I understand that information will only be given to workers of these two agencies who obey the code of confidentiality of the agencies that they represent. I understand that participation in this initiative is voluntary and that I can withdraw my consent and participation at any time.
	Date:*



Referral agency to complete Please complete if you are a referring agency.
Contact name:	Agency:
Contact email:

* Required fields

Client details

Health / benefit details

Referral agency to complete

Unite against COVID-19