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  • REFERRAL

    INTAKE
  • Note: Insufficient or vague information may result in delays or limitations in service allocation, as the assessment relies on the level of detail submitted.

  • I am a...*
  • Incredible Years Parenting Course*
  • The person I'm referring is a...*
  • CLIENT INFORMATION

    Details of the person intended to access services.
  • Date of Birth*
     / /
  • OTHER CONTACTS

  • REFERRER

  • As the referrer, I am continuing to support the individual being referred.*
  • The contacts listed below will be contacted in the order provided, if necessary. 

  • CONTACT 1

    This person will also be treated as a emergency contact
  • Add another contact*
  • CONTACT 2

  • REASON FOR REFERRAL

  • Please provide a clear outline why this referral is being made. Include any relevant background or current factors that have led to the referral - this may include historical information, presenting concerns, behavioural patterns, family context, or key incidents. If there are multiple contributing reasons, outline each as clearly as possible. The aim is to give our team a well-rounded understanding of the situation

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  • WHANAU OF CLIENT

  • List household members and key people involved in the client's life. This provides context around living arrangements and whānau dynamics.
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  • Rows
  • Are there any other supports currently involved with the client or whānau while they are engaged with Parentline services? This may include social workers, counsellors, doctors, schools, agencies, or other organisations providing support.*
  • OTHER SUPPORTS

  • Rows
  • Do you have any supporting documents you would like to attach?*
  • SUPPORTING DOCUMENTS

  • To enhance our understanding of the individual's needs, please attach any relevant documents, assessments, or protection orders.
  • Protection Order*
  • Order Date*
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  • INFORMATION NOTICES

  • Confidentiality and Research

    • Parentline maintains strict confidentiality in all services. Information you provide may be shared only within the Parentline team where necessary to ensure appropriate care and referral support.
    • Your personal information will not be shared with any other agency without your consent, except where required by law — for example, if there are concerns for the safety or wellbeing of a child, another person, or yourself.
    • Some information may be used anonymously for reporting, research, or evaluation purposes to help Parentline improve its services. Any research activity is voluntary and will not affect access to services. All information used for research or statistical purposes will remain non-identifiable.
    • If Parentline ceases to provide services, your file or related data may be transferred to another designated provider or Ministry.
    • Consent can be withdrawn at any time by notifying Parentline in writing
  • Waitlist Notice

    • Parentline receives a high volume of referrals and cannot always provide immediate service. Our clinical team reviews the waitlist weekly and prioritises based on need and other variables.
    • Parentline will maintain regular contact with clients while on the waitlist.
    • You are encouraged to update Parentline if your circumstances change.
    • Wait times vary depending on demand and service capacity.
  • Complaints Notice

    • If you are unhappy with how services have been delivered
    • You can:
      • Speak directly with your caseworker
      • Email a formal complaint to parentline@parentline.org.nz (include your full name, contact details, and complaint summary)
      • If unresolved, contact the Health and Disability Commissioner on 0800 11 22 33, email hdc@hdc.org.nz, or write to P.O. Box 1791, Auckland 1140
  • Information Sharing Consent

    • Under the Family Violence Act 2018, Parentline is recognised as a Family Violence Agency. This means we may share relevant information with other approved agencies to identify, prevent, or respond to family violence.
    • Information may be shared only for:
      • Risk and needs assessment
      • Safety and response planning
      • Protection of victims of family violence
    • Parentline will always consider the safety, wellbeing, and rights of all parties before sharing any information.
    • By signing below, you acknowledge you understand this requirement and consent to information sharing where required by law.
  • Transport Consent

    • Parentline may offer transport for children attending services, depending on staff and vehicle availability.
    • Parent/Guardian Responsibilities:
      • Ensure your child is ready for pick-up and understands seatbelt safety.
      • Inform the school of pick-up/drop-off arrangements.
      • Notify Parentline immediately if your child is absent or unavailable.
    • Parentline Responsibilities:
      • Provide transport only between school and home addresses.
      • Contact the Parent/Guardian immediately if behaviour becomes a concern.
      • Review transport arrangements if issues arise.
  • DECLARATION & CONSENT

  • Referrer Declaration

    • I confirm that I have obtained consent from the individual being referred (or their parent/guardian where applicable) to make this referral and share the information provided. I confirm that the information submitted is accurate to the best of my knowledge and that I am continuing to support the individual where appropriate.
  • Date*
     / /
  • The Client / Parent / Gaurdian is present to sign consent
  • Client / Parent / Guardian Declaration and Consent

    • I/We confirm that the information provided is true and correct to the best of my/our knowledge. I/We have read and understood the information and notices outlined in this form and agree to the terms of enrolment with Parentline. I/We consent to myself/our child engaging in Parentline services.
  • Date*
     / /
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