• Social Worker in Schools Service Referral

    Use this form if you are a Referral Agent or School

  • Child and Family Details

  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Ethnicity*

  • Interpreter or Communication aide required?*
  • Does the child know about this referral?*
  • Number of Household’s Child currently resides in:*
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  • Is it OK to use this email address for communications and notifications?

  • School Information

  • Is the child currently attending school?*
  •  -
  • Has the child had a B4 School Check completed?
  • Does the School know about this referral?*

  • 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*
    Rows

  • 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
    Rows

  • 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
    Rows

  • Child and Adolescent Trauma Screen

  • Being “trauma-informed” matters to Stand Tu Maia. The idea behind trauma-informed services is pretty straightforward: When the approach we provide to children and families is informed by a basic knowledge of “what stressful or scary events have happened to them” and how these traumatic experiences and associated stress have impacted on them, many things are likely to turn out better.

    Stressful or scary events happen to many children. Below is a list of stressful and scary events that sometimes happen. Mark YES if any of these events have happened to the child to the best of your knowledge. Mark NO if the child has not experienced these events to the best of your knowledge.

  • Serious natural disaster like a flood, tornado, hurricane, earthquake, or fire.*
  • Serious accident or injury like a car/bike crash, dog bite, sports injury.*
  • Robbed by threat, force or weapon.*
  • Slapped, punched, or beat up by someone in the family.*
  • Slapped, punched, or beat up by someone not in the family.*
  • Seeing someone in the family get slapped, punched or beat up.*
  • Seeing someone in the community get slapped, punched or beat up.*
  • Someone older touching their private parts when they shouldn’t*
  • Someone forcing or pressuring sex, or when they couldn’t say no.*
  • Someone close to the child dying suddenly or violently.*
  • Attacked, stabbed, shot at or hurt badly.*
  • Seeing someone attacked, stabbed, shot at, hurt badly or killed*
  • Stressful or scary medical procedure.*
  • Being Around War.*
  • Other stressful or scary event*

  • Referrer Details

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  • Lead Agency for Family*
  • Any current Care and Protection Concerns?*
  • Is the child known to Oranga Tamariki ?*
  • Other Agencies/services Currently Involved

  • Expectation of Stand Tū Māia Social Work in Schools service*

  • Consent to Referral

  • Has this referral been discussed with the child's family?*
  • As the referring agent, I can confirm the parent/caregiver(s) has provided verbal consent to sending this referral to Stand Tū Māia*
  • 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:*
  • 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:*
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  • Please click PREVIEW to check your form and SUBMIT only when you have completed the form - you will not be able to edit it once it has been submitted.

     

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