Family Start Referral Form

Family Start Development Referral Form

Matua/Parent/Primary Caregiver’s Name:(Required)

First Last

Age(Required)

Date of birth(Required)

Address(Required)

Street Address Address Line 2 City Post Code

Phone(Required)

Email(Required)

Mātāwaka/Ethnicity(Required)

Iwi

Matua/Parent/Primary Caregiver’s Name:

First Last

Age

Date of birth

Address

Street Address Address Line 2 City Post Code Country

Email

Phone

Mātāwaka/Ethnicity

Iwi

Is this form filled out on behalf of a child?(Required)

Yes

No

Tamaiti / Child Details

Name / ingoa

First Last

Gender(Required)

Female

Male

Date of birth(Required)

NHI Number(Required)

GP(Required)

Well Child Provider(Required)

LMC(Required)

Mātāwaka/Ethnicity(Required)

Dependants

Name

First Last

Gender

Female

Male

Date of birth

Relationship

Mother, Father, Cousin etc.

Name

First Last

Gender

Female

Male

Date of birth

Relationship

Mother, Father, Cousin etc.

Name

First Last

Gender

Female

Male

Date of birth

Relationship

Mother, Father, Cousin etc.

Name

First Last

Gender

Female

Male

Date of birth

Relationship

Mother, Father, Cousin etc.

Name

First Last

Gender

Female

Male

Date of birth

Relationship

Mother, Father, Cousin etc.

Name

Contact Details

Name

Contact Details

Name

Contact Details

Reasons for Referral (please complete any box that is relevant)

e.g. Emotional, behavioural, educational, parenting, health, whānau/relationship difficulties.

Any Immediate Specific Safety Concerns

eg. dogs, gangs etc

Referral Criteria

Oranga Tamariki Involved – Oranga Tamariki are currently involved with my family or have been involved in the past.

Child Development – I am concerned about my child’s development.

For example: I struggle with caring for my baby and meeting their health needs, I had late or very little ante-natal or post-natal care, My baby has a disability or special needs.

History of Child Abuse

For example: As a child I experienced some abuse.

Alcohol/Drug/Gambling Abuse

For example: The amount that I drink/use drugs/gamble is a problem.

Mental Health

For example: I have or have had some issues with my mental health.

Relationship Problems

For example: I have had some serious problems with family/partner relationships

Young Parent

For example: I am under 18, and I have other challenges. (Refer to list B below)

Police Involvement

For example: I have been in trouble with the police

Low Income Status

For example: I find it hard to manage with the money I have

Frequent change of address

For example: I have changed address more than once in the last 6 months

Unsupported Parent

For example: I do not have family or friends around to help me. I feel isolated.

Low Parental Education

For example: I struggled at school, left early, and have few qualifications. I find learning hard.

SUDI

For example: I smoked while I was pregnant, My baby has not been breast fed – or was for a short time only, My baby was a low birth weight. My baby was premature, My baby was or is exposed to second hand smoke, I have had other babies with low birth weight

Referrer Information

Referral From(Required)

Agency/Kura(Required)

Address(Required)

Street Address Address Line 2 City Post Code Country

Phone(Required)

Email(Required)

Signature(Required)

Date(Required)

Client Signature(Required)

Date(Required)

Email

Email: general@hauraki.iwi.nz

Phone: 07 862 7521

Freephone: 0508 4682 88

41 Belmont Rd

Paeroa, 3600