Family Works HB Referral Form
Referred By
*
First Name
Last Name
Position
Organisation
Contact Number
Referrer Email
example@example.com
Date
-
Day
-
Month
Year
Date
Family / Whānau Details
Parent/Caregiver 1
Parent/Caregiver
*
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
Relationship to child/children
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
Is it safe to leave a message
Best time to contact
Email
example@example.com
Ethnicity 1
Iwi
Ethnicity 2
Iwi
Hapū
Parent / caregiver has day to day care
Yes
No
Unsure
N/A
Parent / caregiver has additional guardianship
Yes
No
Unsure
N/A
Parent/Caregiver 2
Parent/Caregiver
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
Relationship to child/children
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Is it safe to leave a message
Best time to contact
Email
example@example.com
Ethnicity 1
Iwi
Ethnicity 2
Iwi
Hapū
Parent / caregiver has day to day care
Yes
No
Unsure
N/A
Parent / caregiver has additional guardianship
Yes
No
Unsure
N/A
Children/Siblings (Please Complete)
How many children (Please remember to add the referred child and all siblings)
*
1
2
3
4
5
6
1 Child
*
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
School/Early Childhood Centre
2 Child
*
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
School/Early Childhood Centre
3 Child
*
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
School/Early Childhood Centre
4 Child
*
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
School/Early Childhood Centre
5 Child
*
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
School/Early Childhood Centre
6 Child
*
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Gender
School/Early Childhood Centre
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Family/Whānau
Family/Whānau Demographics
Single Parent
2 Parent Family
Grandparents Parenting
In care of Whānau
In care of Oranga Tamariki
Day to day care
Family/Whānau Income
Employed full/part time
Benefit
Income unknown
Accessibility
Does the family/whānau need support to access services?
Does the family/whānau need interpreter services?
What is the first language of the family/whānau?
Are there any issues that you as the referrer are aware of?
Safety Concerns for Staff Member
*
Yes
No
Unsure
Dogs on property
*
Yes
No
Unsure
Mental health / Physical health
*
Yes
No
Unsure
Protection orders
*
Yes
No
Unsure
Non-association order / PSO / Trespass Order
*
Yes
No
Unsure
Gang Affiliations
*
Yes
No
Unsure
Details on any of the above
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Service Required
Social Workers in Schools
Whakamana Whānau Social Work
Counselling
Ministry of Justice
Programmes
Programmes
Te Haerenga Hou
Poipoi Mokopuna
Whakamanawa Mātua
CHB – Te Haerenga Hou
CHB - Whakamanawa Mātua
Tamariki Taonga (Child Safety programme)
Tūhono Tamariki (Child Social Skills programme)
Te noho Haumaru-ā-Ipurangi (Child Online Safety programme)
Whakaratangia o kare-ā-roto (Child Emotional regulation programme)
Family Works will advise the referrer of the outcome of this referral and / or make suggestions of more suitable services if we are unable to work with this family / whānau
The Family Works team cannot work with any young person without the consent of the parent or legal guardian.
Family/Whānau are aware of this referral to Family Works HB
Yes
No
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Reason for Referral
Please identify the whānau member(s) here that require support and outline the reasons for the referral. Be as specific as possible.(Please note that this text box will extend as you continue to type.)
Please ensure information we receive is accurate and to the best of your knowledge
Yes
Family Works staff member who took referral
Reference Number
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