no
Step 1
Step 2
Step 3
Step 4
navigation_horizontal_round
1
#00548f
in_fadeIn next_fadeInRight back_fadeInLeft
no
0
#0073aa
off
Student Details
Referral Date (DD/MM/YYYY) *
[text* cf-referral-date /100]
Full Name *
[text* cf-student-full-name /250]
Country of Birth *
[text* cf-student-country-birth /150]
Ethnicity *
[text* cf-student-ethnicity /150]
D.O.B. *
[text* cf-student-dob /100]
Age *
[text* cf-student-age /100]
Gender
[checkbox* cf-student-gender use_label_element exclusive “Male” “Female”]
Iwi / Hapu
[text* cf-student-iwi-hapu /150]
[cf7mls_step cf7mls_step-1 “Next” “Step 1”]
Family Details
Parent / Caregiver Name(s) *
[text* cf-caregiver-names /250]
Address *
[textarea* cf-caregiver-address x3 /350]
Home Phone *
[tel* cf-caregiver-home-phone /150]
Email *
[email* cf-caregiver-email /250]
Relationship to Student *
[text* cf-relationship-student /150]
Mobile *
[tel* cf-caregiver-mobile /100]
Occupation *
[text* cf-caregiver-occupation /150]
[cf7mls_step cf7mls_step-2 “Back” “Next” “Step 2”]
Referrer Contact Details
Referrer Name *
[text* cf-referrer-name /250]
Position *
[text* cf-referrer-position /250]
Work Phone *
[tel* cf-referrer-work-phone /150]
Email *
[email* cf-referrer-email /250]
Fax
[text* cf-referrer-fax /150]
Reason/s for Referral (details of incident/s, frequency, severity)
[textarea cf-reasons-referral x3 /350]
What would you like SWIS to do?
[textarea cf-swis-to-do x3 /350]
[cf7mls_step cf7mls_step-3 “Back” “Next” “Step 3”]
Other Professionals Involved
[checkbox cf-professionals-involved use_label_element “Public Health Nurse” “Police” “RTLB” “GSE” “Child Youth & Family” “Other”]
Student / Whanau Consent
Have you discussed this referral with the student or whanau concerned?
Whanau
[checkbox* cf-consent-whanau use_label_element exclusive “Yes” “No”]
Student
[checkbox* cf-consent-student use_label_element exclusive “Yes” “No”]
Consent
[acceptance acceptance-454] I/We consent to being referred to SWiS. [/acceptance]
Signature *
[signature* cf-referral-signature]
[submit “Submit”][cf7mls_step cf7mls_step-4 “Back” “Step 4”]
1
ATWC Website – SWiS Referral | [cf-student-full-name]
[_site_title] <[email protected]>
[email protected]
You’ve recieved a new referral to SWiS
Student Details
Referral Date (DD/MM/YYYY): [cf-referral-date]
Full Name: [cf-student-full-name]
Country of Birth: [cf-student-country-birth]
Ethnicity: [cf-student-ethnicity]
D.O.B.: [cf-student-dob]
Age: [cf-student-age]
Gender: [cf-student-gender]
Iwi / Hapu: [cf-student-iwi-hapu]
Refer to the attached pdf file for the full referral details.
—
This email was sent from SWiS Referral form on [_site_title]
Reply-To: [cf-caregiver-email]
1
[_site_title] “[your-subject]”
[_site_title] <[email protected]>
[your-email]
Message Body:
[your-message]
—
This email was sent from a contact form on [_site_title] ([_site_url])
Reply-To: [_site_admin_email]
Thank you for your message. It has been sent.
There was an error trying to send your message. Please try again later.
One or more fields have an error. Please check and try again.
There was an error trying to send your message. Please try again later.
You must accept the terms and conditions before sending your message.
The field is required.
The field is too long.
The field is too short.
There was an unknown error uploading the file.
You are not allowed to upload files of this type.
The file is too big.
There was an error uploading the file.
The date format is incorrect.
The date is before the earliest one allowed.
The date is after the latest one allowed.
The number format is invalid.
The number is smaller than the minimum allowed.
The number is larger than the maximum allowed.
The answer to the quiz is incorrect.
The email address entered is invalid.
The URL is invalid.
The telephone number is invalid.