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Organisation / Agency Name

Role / Position

New Zealand European Māori Samoan Cook Islands Māori Tongan Niuean Tokelauan Fijian Other Pacific Peoples Chinese Indian Southeast Asian Other Asian Middle Eastern Latin American African Other Ethnicity Prefer not to say

Kahurangi / Family Start – Additional Information

Primary Caregiver

Tamariki Information

Well Child Provider

Relevant concerns / circumstances (tick all that apply)

Mental health issues Addiction problems Childhood history of abuse Care or protection history Relationship problems Parenting and development issues Young parents (under 18 years of age) Sudden unexplained death indicators Multiple births Lack of positive support networks Criminal justice involvement Financial and material resource difficulties Frequent change of address Low parent education

Ūkaipō – Additional Information

Please confirm ethnicity, address and phone (can be pre-filled from client details).

Primary Mental Health & Addictions – Supports Requested

Stress Low mood/depression Grief Alcohol and other drug support Anxiety Social isolation Post/prenatal Addiction Something else

Disclosure of any risk (substance use, harm to self/others, previous attempts, violence in the home, etc.)

Whānau-Centred / Family Harm – Primary Caregiver

We may need to confirm consent before providing services.

1 About the Referrer

2 Whānau / Client Details

3 Referral Details

Kahurangi / Family Start – Additional Information

Ūkaipō – Additional Information

Primary Mental Health & Addictions – Supports Requested

Whānau-Centred / Family Harm – Primary Caregiver

4 Whānau Consent

5 Declaration & Review