SWiS Referral CF7

Step 1
Step 2
Step 3
Step 4

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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]

[checkbox* cf-student-gender use_label_element exclusive “Male” “Female” “Non Binary” “Prefer Not To Answer”]

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 cf-caregiver-email /250]

Relationship to Student *
[text* cf-relationship-student /150]

Mobile *
[tel* cf-caregiver-mobile /100]

[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]

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]

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?

[checkbox* cf-consent-whanau use_label_element exclusive “Yes” “No”]

[checkbox* cf-consent-student use_label_element exclusive “Yes” “No”]

[cf7mls_step cf7mls_step-3 “Back” “Next” “Step 3”]


[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”]
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]


[_site_title] “[your-subject]”
[_site_title] <[email protected]>
Message Body:

This email was sent from a contact form on [_site_title] ([_site_url])
Reply-To: [_site_admin_email]

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