Please contact Jigsaw Whanganui if you have any questions while completing this this form – see contact details at end of form.
Request for Service
Date
-
Month
-
Day
Year
Date
Children/Young Person/s Under 18
Rows
Child/s first and last name
Gender M/F/GD
DOB
Ethnicity IWI
School/ECE name
1
2
3
4
Rows
Parent/Caregiver/Adult Names
Gender M/F/GD
DOB
Ethnicity IWI
Relationship to child
1
2
3
4
Address
Phone
Format: (000) 000-0000.
Phone
Format: (000) 000-0000.
Email
example@example.com
Name of agency referring this Whanāu
Name
Relationship with family or whānau
Ph
Format: (000) 000-0000.
Email
example@example.com
Does the family or whānau agree to have a first meeting with Jigsaw Whanganui?
YES
NO
Does the family or whānau agree to you providing information about them to Jigsaw Whanganui?
YES
NO
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IDENTIFYING CONCERNS
To be completed at referral or if self-referring in first meeting with Jigsaw. Our team at Jigsaw Whanganui assist people, whānau and families to work through barriers and achieve their goals. To assist us to decide how best Jigsaw Whanganui, or another service, can assist you and/or your family, please tick (1) the appropriate box for each statement. All responses will be treated respectfully and in confidence. Feel free to write a comment in the space below each statement.
IDENTIFYING CONCERNS
Rows
NOT AT ALL
ONLY A LITTLE
QUITE A LOT
A GREAT DEAL
Comment
Our family has undergone major changes over the past 12 months e.g. relationship breakdown, moving home, new children entering the family.
Our home is not functioning well, and we have difficulties getting adequate support and resources (money, housing, food and support networks) to manage.
People have raised concerns regarding our children's safety. Oranga Tamariki are/ have been involved with our family.
Members of our family are facing police and or court proceedings -criminal, family, civil - - if yes, please state type of charges.
People in our family are presently being subjected to abuse and/or violence; children are hearing and witnessing violence.
An adult in our family has experienced abuse and or violence in their childhood.
The child/ren have been diagnosed with serious developmental or learning needs e.g. FAS, ADD, ASD.
I/we are very concerned about our child/ren's education and learning.
Someone in our family/household has a chronic illness and/or disability.
My/our family/household is affected by the use of alcohol and/or drugs (including tobacco).
We are facing difficulties with work, un/employment, or training.
The children's behaviour is out of control.
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What are the concerns around which you/your family or whānau is seeking assistance of Jigsaw Whanganui?
How have you/your family or whānau (and others) already tried to deal with these concerns?
What support are other services providing? (name the services)
What are you/your family's/whānau strengths and resources?
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What would you/your family or whānau like to be different by engaging with Jigsaw Whanganui?
Is there anything else you would like to tell us?
Thank you for giving us this information. We will be in contact with you within 7 days.
Suite 10, 236 Victoria Avenue, PO Box 4295, Whanganui 4541, New Zealand
Ph: +64 (0)6 345 1636 email:
admin@jigsawwhanganui.org.nz
www.jigsawwhanganui.org.nz
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