03 687 7945 (PSSC) | 03 688 5029 (Family Works)
admin@pssc.co.nz
Visit PS National Website
Menu
Home
News & Events
About Us
Meet Our People
What We Do
Resources
Royal Commission Inquiry – Abuse In Care
Get Involved
‘In Bloom’ Fundraising Raffles
Enliven
Options & Choices
Residential Aged Care
The Croft Home
Blended Rest Home & Hospital Care
Specialist Dementia Care
Margaret Wilson Home
Margaret Wilson Rest Home Care
Margaret Wilson Hospital Level Care
Margaret Wilson Hornsey Home
Wallingford Home
Strathallan Lifecare & Healthcare
Respite Care
Retirement Living
Units & Apartments at The Croft
Rental Cottages at Margaret Wilson
Rental Cottages at Wallingford
Eden Alternative
Enliven Te Pokapū (The Hub)
Staying in Your Own Home
Home Support
Community First
Private Paying Clients
Enliven Te Pokapū (The Hub)
Respite Care
Retirement Living
Frozen Meals
Activities & Outings
Family Works
Donate to Filling our Emergency Family Foodbank
McCain Christmas on the Bay Family Works Fundraiser
The Christmas Angel Project
Children
Family Social Work
Family Start
Family Start Referral Form
Child & Family Psychologist
Children’s Programmes
Power Up
Free to be Me for Children
Social Workers In Schools
Buddy Mentoring Programme
Counselling
Family Works Parenting Programmes
Parenting Through Separation
Family Works Child Protection Policy
Family
Family Social Work
Family Start
Family Start Referral Form
Child & Family Psychologist
Counselling
Social Workers In Schools
Family Violence Services
Free to be Me – Women’s Programme
Free to be Me – Child’s Programme
Family Works Parenting Programmes
The Incredible Years
Parenting Through Separation
Grandparents Raising Grandchildren
Frozen Meals
Me
Counselling
Self Help Resources & Links
Community Services & Support Networks
Self Help Resources & Links
About Family Works
Family Works Jobs
Contact Us
Refugee Settlement Services
About this service
Volunteer
Donate
Homestead Heritage Project
Restoration
Restoration Plans & Updates
History of The Croft
Get Involved
Fundraising Events & Activities
Social Shares & Updates
Sponsorship
Donate
Donate
Donate
Presbyterian Support Bequests
Jobs
Volunteer
Contact Us
Family Works Request for Service Form – Self/Family
Home
Family Works Request for Service Form – Self/Family
Request for Service Form - Self Referral Family Works
Client Details
First Name
*
Middle Name
*
Surname/Family Name
*
Date of Birth
*
DD slash MM slash YYYY
Ethnicity/Iwi:
*
Country of Birth:
*
Gender
*
Male
Female
First Name
Middle Name
Surname/Family Name
Date of Birth
DD slash MM slash YYYY
Ethnicity/Iwi:
Country of Birth:
Gender
Male
Female
Family/Whanau Details
Name
Date of Birth
DD slash MM slash YYYY
Gender
Male
Female
Ethnicity/Iwi:
Relationship to client
Name
Date of Birth
DD slash MM slash YYYY
Gender
Male
Female
Ethnicity/Iwi:
Relationship to client
Name
Date of Birth
DD slash MM slash YYYY
Gender
Male
Female
Ethnicity/Iwi:
Relationship to client
Name
Date of Birth
DD slash MM slash YYYY
Gender
Male
Female
Ethnicity/Iwi:
Relationship to client
Contact Information/Details:
Address
*
Street Address
Address Line 2
City
Region
Postal Code
Landline Phone No.
*
Mobile
*
Mobile
Email
*
Clients preferred way of contact:
Mobile
*
Yes
No
Landline
*
Yes
No
Letter
*
Yes
No
Text Message
*
Yes
No
Voice Message
*
Yes
No
Email
*
Yes
No
What are the best times to contact you?
*
Day
Morning
Afternoon
Evening
What times are you available for sessions/visits?
*
Day
Morning
Afternoon
Evening
What are the concerns that have prompted this request for service?
Please specify below
*
Family Works Service Required
Service/Programme Referred for:
*
Are you currently working with Family Works:
*
Yes
No
Not known
Have you used our services before?
*
Yes
No
Not known
If yes which service:
Other Agencies or Professionals Involved
Agency
Name
Contact Phone No.
Involvement
Agency
Name
Contact Phone No.
Involvement
Agency
Name
Contact Phone No.
Involvement
Concerns/Safety
Are there any safety concerns for you or anyone in your family?
*
Yes
No
Do you have a current Protection Order
*
Yes
No
If Yes to either of the above please give more information:
On a scale of 1 – 5 (1 being little impact and 5 being great impact):
*
How much is the issue impacting you today?
1
2
3
4
5
On a scale of 1 – 5 (1 being well supported and 5 unsupported):
*
How supported do you currently feel?
1
2
3
4
5
Self-Referrer
Is this a self-referral?
*
If no please complete the next section.
Yes
No
Other Request for Service Information
If no, how are you connected or related to the person to the person being referred?
Has the person agreed to this Request for Service?
Yes
No
Name
Phone No.
Mobile No.
Email
Date
DD slash MM slash YYYY
Menu
