WEBSITE REFERRAL | Jigsaw North Manaaki Whānau

Client

Who will be using the services? Eg. child, whānau member, parent.

Name of client*

School (if child)

Date of birth*

Gender*

Ethnicity*

Iwi/hapū*

Is the client under 18 or requires a caregiver contact?*

No Yes

Parent/caregiver

Name*

Relationship*

Date of birth*

Gender*

Ethnicity*

Iwi/hapū*

Service requested*

Counselling Social work Seasons for Growth (Adults) Seasons for Growth (Children)

Parenting Programme

Contact

Phone*

Email*

Address*

Partner/additional children

Additional caregiver or emergency contact

Please select from the options below

Name

Relationship

Email

Phone

Referrer details

Myself Another person

Name

Organisation

Role

Phone

Email

Is the client aware and consents to the referral?*

No Yes

Screening questions

Do you have children under 18 years?*

No Yes

Are any children currently in your care?*

No Yes

If separated, is there shared guardianship/custody?

No Yes

Do you have upcoming Family Court or Family Group Conference Dates (FGC)?*

No Yes

Do you have Mental Health needs/history – diagnosed or undiagnosed?*

No Yes

Have you experienced suicidal thoughts and/or feelings?*

No Yes

Do you have any needs that we should be aware of in our interaction with you?*

e.g. hearing or sight impaired.

No Yes

Please list any other agencies involved

Other information

What is happening now?*

Please give us as much information as you are comfortable sharing around the reason for this referral. It will help us to triage the urgency and allocate the referral.

Referral form

Date*

Client

Name of client*

School (if child)

Date of birth*

Gender*

Ethnicity*

Iwi/hapū*

Is the client under 18 or requires a caregiver contact?*

Parent/caregiver

Name*

Relationship*

Date of birth*

Gender*

Ethnicity*

Iwi/hapū*

Service requested*

Parenting Programme

Contact

Phone*

Email*

Address*

Partner/additional children

Additional caregiver or emergency contact

Please select from the options below

Name

Relationship

Email

Phone

Referrer details

Name

Organisation

Role

Phone

Email

Is the client aware and consents to the referral?*

Screening questions

Do you have children under 18 years?*

Are any children currently in your care?*

Please enter the number of children below*

If separated, is there shared guardianship/custody?

Please give details

Do you have upcoming Family Court or Family Group Conference Dates (FGC)?*

Do you have Mental Health needs/history – diagnosed or undiagnosed?*

Please give details*

Have you experienced suicidal thoughts and/or feelings?*

When?*

Do you have any needs that we should be aware of in our interaction with you?*

Please explain*

Please list any other agencies involved

Other information

What is happening now?*

Our whakataukī