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Unite against COVID-19 – New Zealand is on Alert Level 2

Workwise is open but only available by phone – 0508 869 675 (free to phone number) or alternatively text us 027 372 3153 with your name and the region you live in. Please observe the guidelines for Alert Level 2.

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:

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Client details

Health / benefit details

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Unite against COVID-19 – New Zealand is on Alert Level 2