Family Start Referral

Complete the referral form below.

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    Step 1

    Referral Criteria

    List A. (Need to have at least one indicator in this section)

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

    History of child abuse
    As a child I experienced some abuse.

    Mental health
    I have or have had some issues with my mental health.

    Young parent
    I am under 18, and I have other challenges. (Refer to list b below)

    Relationship problems
    I have had some serious problems with family/partner relationships.

    Alcohol/Drug/Gambling abuse
    The amount that I drink/use drugs/gamble is a problem.

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

    • 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.

    List B. (Need to have at least 3 indicators in this section. Please provide details about how they affect the parent’s/caregiver’s ability to care for the child.)

    Police Involvement
    I have been in trouble with the police.

    Frequent change of address
    I have changed address more than once in the last 6 months.

    Low parental education
    I struggled at school, left early and have few qualifications. I find learning hard.

    Low income status
    I find it hard to manage with the money I have.

    Unsupported parent
    I do not have family or friends around to help me. I feel isolated.

    SUDI
    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.

    Primary Caregiver

    Parent/Primary caregiver's name *

    Relationship to child *

    Age *

    DOB *

    Address *

    Phone *

    Mobile *

    Email *

    Ethnicity

    Tribal affiliations

    Add New

    Baby

    Baby's name *

    DOB/EDD *

    NHI number

    GP

    Well child provider

    LMC

    Ethnicity

    Dependents

    Dependent's name

    DOB

    Dependent's name

    DOB

    Dependent's name

    DOB

    Dependent's name

    DOB

    Dependent's name

    DOB

    Housing

    Significant Others (Whanau, Neighbors, Friends)

    Name

    Contact details

    Name

    Contact details

    Name

    Contact details

    Name

    Contact details

    Referral Details

    Reason for referral

    Specific concerns (ex dogs, gangs, others)

    Referrer Information

    Referral From *

    Address *

    Date *

    Agency *

    Phone No *

    Email *

    IMPORTANT: CONSENT FOR FAMILY START REFERRAL/TRANSFER

    Signature *