To ensure your referral is accepted and actioned immediately, it is vital that we receive the complete information requested (referral document and check list). If you are not an audiologist fill in the form as best you can.
The referral will not be processed until we have all essential information so getting the name of your client’s audiologist will make the process faster.
If your client does not meet referral criteria we are happy to arrange a private assessment on receipt of this form.
Public Referral Criteria
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NZ Residency
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Adults will not be able to access services in the publically funded programme if they do not hold NZ citizenship or residency. (Potential candidates must also live in New Zealand for at least 183 days per year).
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Information Required
Copy of client’s New Zealand birth certificate, passport or New Zealand residency visa.
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Baseline Audiometric Criteria
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Presence of a severe hearing handicap as evidenced by speech audiometry that is ≤ 60% in the better hearing ear. (Pimax on CVC or AB words).
Clients must previously have had sufficient hearing to have developed some spoken language.
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Information Required
Please attach all the following audiological information:
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Current diagnostic audiogram (speech audiometry, immittance audiometry, and if available otoacoustic emissions)
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Previous audiograms & speech audiometry
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Copies of any ENT reports (if available)
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Hearing Aids
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Hearing aids and moulds need to be optimized for the loss. If prescriptive targets have not been met make note of why this has occurred. If there is no residual hearing ear moulds are required to assess lip reading benefit.
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Information Required
Please enclose:
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Print out of settings
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Real ear measures
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Private Referral Criteria
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Baseline Audiometric Criteria
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Presence of a severe hearing handicap as evidenced by speech audiometry that is ≤ 60% in either ear. (Pimax on CVC or AB words).
Clients must previously have had sufficient hearing to have developed some spoken language.
​
Information Required
Please attach all the following audiological information:
-
Current diagnostic audiogram (speech audiometry, immittance audiometry, and if available otoacoustic emissions)
-
Previous audiograms & speech audiometry
-
Copies of any ENT reports (if available)
​
​
​​
Hearing Aids
​
Hearing aids and moulds need to be optimized for the loss. If prescriptive targets have not been met make note of why this has occurred. If there is no residual hearing ear moulds are required to assess lip reading benefit.
​
Information Required
Please enclose:
-
Print out of settings
-
Real ear measures
​
​
​
​
The Northern Cochlear Implant Trust holds contracts with the Ministry of Health and Ministry of Education for the Northern Cochlear Implant Programme. Patients eligible for a publicly funded cochlear implant receive services from the providers below:
Thank you for your referral.
