SWiS Referral - Referral Agent

Details of all people living at child’s address

Please include other children and note if the person is a Legal Guardian

People who live at the child's address*

Other Significant People NOT living with the child

Please include other children but exclude service providers

Other significant people who do not live with the child

If the legal guardian does not live at the child’s address, please provide the contact details of all legal guardians as we are required to advise all legal guardians of our service involvement with the child.

Legal Guardian(s) not living at child's address

Referrer Details
Referral agent name*

First NameLast Name
Agent Role*
Agency*
Agency Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Agency Postal Address (if different)

PB Box/Private Bag

CityState / Province

Post Code
Agency Phone number

Area CodePhone Number
Referral Agent Mobile

PrefixPhone Number
Referral agent email*

Confirmation EmailA copy of the filled form will be sent to this address so please enter twice to confirm accuracy
Lead Agency for Family*

YesNoUnsure

Consent to Referral
Has this referral been discussed with the child's family?*

YesNo
As the referring agent, I can confirm the parent/caregiver(s) has provided verbal consent to sending this referral to Stand Tū Māia*

YesNo
As the referring agent, I can confirm the parent/caregiver(s) understands that if this referral is accepted, it will lead to an assessment of the child and family’s needs and an agreed response, which may or may not include agreeing to a child and family plan to receive a range of services to support the family goals:*

YesNo
As the referring agent, I can confirm the parent/caregiver(s) has given permission for Stand Tū Māia Services staff to document and gather information for the purpose of undertaking an assessment:*

YesNo
Parent/Caregiver Name

First NameLast Name
Parent/Caregiver Name

First NameLast Name
Please attach any Supporting Documents or Letters

Browse Files

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Referral Type
Should be Empty:

Social Worker in Schools Service Referral