KIA ORA AKE Referral Form
Support Referral
*
I’m a whanau member / caregiver seeking support for a tamariki
I’m a teacher / school seeking support for a tamariki
Kia Ora Ake Referral Form for Individual, Whaanau, and/or Small Group Support
Please fill in the following form and email this to (providers email)
Child's Full Name (include preferred name if applicable)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
D.O.B.
*
-
Month
-
Day
Year
Date
NHI No. (if available)
Gender
*
Male
Female
Other
Ethnicity/ Ethnicities
*
New Zealand European
Maaori
Iwi
Samoan
Cook Island Maaori
Tongan
Niuean
Chinese
Indian
Other
GP details (if available)
Other services involved in supporting the child
Primary care
Church
Oranga Tamariki
CAMHS
RTLB
Kaikaranga (Taikura Trust)
Don't know
Other
Please provide a name and contact details for supports identified above:
Name:
Contact:
Organisation:
Name:
Contact:
Organisation:
Name:
Contact:
Organisation:
Shared Care and Legal Guardianship
We understand every whaanau is different, and we want to make sure the right people are included and
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supported. Please let us know who the important adults are in this child's life.
Are there any shared care or custody arrangements we should be aware of?
Yes
No
Unsure
If yes, feel free to share any details that might help us support your whaanau well (e.g. routines, care schedules, communication preferences):
Legal Guardian Contact Details
Please list all legal guardians for this child (e.g. both parents, whaanau members with legal care):
(If a legal guardian is also the emergency contact below, you can just write "see below" for contact details)
Full Name
First Name
Last Name
Relationship to Child
Address (if different from child's)
Full Name
First Name
Last Name
Relationship to Child
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address (if different from child's)
Phone Number
Format: (000) 000-0000.
Email
example@example.com
I confirm that all listed legal guardians are aware of and consent to this referral.
If you're unsure or would like to talk this through, our team is happy to help.
Emergency Contact Details
Full Name
First Name
Last Name
Relationship to Child
Phone Number
Format: (000) 000-0000.
Address (if different from child's)
Email
example@example.com
Please include names and DOB of siblings if appropriate
Please tick the type of support you are requesting:
Individual
Whaanau
October 2025
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KIA ORA AKE
Please tick the relevant wellbeing needs that best describe the child's current experiences:
Anger
Anxiety
Bullying
Cultural reconnection/connection
Gaming/Screen Time/Social Media
Emotional Regulation
General Wellbeing
Goal-Setting
Grief/loss/ changes
Identity
Low mood
Mana Enhancing
Neurodiversity support
Family conflict/distress/changes
Peer relationships
Sleep
Stress
Transitions into new school or year group
Vaping
Whaanau Support
Other
Are there other needs we should be aware of? e.g. sensory, behavioural, health, and cognitive needs
Are there any immediate safety concerns or risks you are aware of that may affect the child, their whaanau or others in their environment? If so, please describe.
Additional Information E.g. strengths, challenges, preferences, or anything else relevant to the child's support.
Referrer Name
Relationship to Child
Contact Details
Signature
Date
-
Month
-
Day
Year
Date
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