Agency/Professional Referral Form

By completing this form you are consenting for us to collecting and storing your information. We are committed to protecting your privacy and ensuring the confidentiality of your personal information. The information we collect from you is used solely for the purpose of providing and enhancing our support services. We will not share your information with third parties without your consent, except in circumstances where we are required or permitted by law. This statement is in accordance with the Privacy Act 2020 and Health Information Privacy Code 2020.

As you have indicated you have not received Client consent to make this referral please ask for consent before proceeding,

or call us on 0800 227 233

eg. touching, verbal, penetration, online, exposure to pornography

(e.g. Maori/Samoan/European)

Street Address

Suburb

Town/City

Area CodePhone Number

Please enter an email as well as contact number where possible to ensure we can get hold of the client.

Only enter information if Contact Number is someone other than the client

Phone CallText/SMSEmailVoicemail

Area CodePhone Number

Any other children?Current mood? (suicidality, self-harm, low mood)Physical symptoms?Any worries or concerns client is having?Risk or safety issues (e.g. alleged offender whereabouts, family violence,)No specific concerns

What other agencies are involved?Does the person have any other special needs or accessibility requirementsAre there potential barriers to accessing our service (e.g. transportation)Does this person present any risks to our staff?No further information

(If you are concerned about the wellbeing of a child, or want to discuss, report, or refer a concern, contact Oranga Tamariki: Phone 0508 EDASSIST (0508 332 774)

(e.g. Police/Mental Health/Oranga Tamariki

(e.g. suicidality, self-harm, family violence, perpetrator whereabouts)

(e.g. emotional, functional and technical)

(e.g. transportation)

(e.g. history of aggression)

Agency/Professional Referral Form

In this section please enter the client's information