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Aatea Referral Form
Consent written or verbal by the family/whanau must be given, due to information sharing within agencies
Consent has been given by family/whanau to make referral?
*
Yes, consent has been given
No, consent has not been given
Child/Tamariki being referred:
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Email Address
*
Address
*
Iwi (if known)
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Triage?
Yes
No
Does the te tamaiti or rangatahi have these presenting issues can we please add tick boxes and maybe a brief description tab below.
Substance abuse
Alleged emotional abuse
Neglect
Anti-social behaviour
Behavioural issues
Grief i.e bereavement
Sexual Exploitation/Harm
Family Harm
Education - High absenteeism, exclusion, stood down
Struggling financially
Bully
Housing-at risk of being homeless
Disability- Intellectual, physical- communication, long-term health issues
Mental Health- General
Parental imprisonment or Parental difficulties
Personal care
Self-harm
Social isolation
Other- Please specify
Other- Please specify
Please give a brief description
Has te tamaiti or rangatahi been seen?
Yes
No
Strength needs and desired outcomes:
Tamarki health and development needs.
Whanau Views
Tamarki - What would you like to change?
Tamarki - How can we help you make this happen?
Kaitiaki Tamarki - How can we make this happen for you?
Kaitiaki Tamarki - How can we make this happen for you?
Kaitiaki Tamariki and capacity
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Add Another Child?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
School
*
Date Of Birth
*
+
Address
*
Iwi (If known)
Referrer's Contact Details:
Referrer's First Name
*
Referrer's Last Name
*
Relationship
*
Agency
*
Contact Phone
*
Contact Email
*
Date
*
+
Parent/Caregivers Details:
First Name
*
Last Name
*
Gender
*
Male
Female
Ethnicity
*
Relationship to child
*
Date Of Birth
*
+
Phone:
*
Email Address:
Address
*
Location
*
Homai/Clendon
Manurewa
Papakura
Takanini
Other
Iwi (if known)
Add another parent?
*
Yes
No
First Name
Last Name
Gender
Male
Female
Ethnicity
Relationship to child
Date Of Birth
+
Phone:
Email Address:
Address
Location
Homai/Clendon
Manurewa
Papakura
Takanini
Other
Iwi (if known)
Current Agencies Involved:
What challenges are the tamariki or Rangatahi experiencing? How could aatea help? Are there any other presenting concerns for the whanau?
*
Agency
*
Contact Name
*
Contact Number
*
Contact Email
*
Add Extra Agency?
*
Yes
No
Agency
Contact Name
Contact Number
Contact Email
Add Extra Agency?
*
Yes
No
Agency
Contact Name
Contact Number
Contact Email
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