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Family Start Referral Form

Home Family Start Referral Form
  • Please enter your name here.
  • If you do not work for a social services agency and this is a private or self referral, please enter "Self Referral".
  • Please enter your email address as we will contact you about this referral. A copy of the completed referral form will be sent to this email address.
  • DD slash MM slash YYYY
  • Family Start is a voluntary programme. Do you have consent from the family for this referral? If you do not have consent from the Primary Caregiver, this referral can not proceed.
  • DD slash MM slash YYYY
  • Please enter the Iwi of the Parent/Primary Caregiver, if applicable.
  • Please select which option best describes the relationship between the Primary Caregiver and the Baby/Child.
  • If you selected other above, please describe the caregiver's relationship to the Baby / Child e.g. Grandmother, Aunt etc.
  • Please enter the best contact number for the Primary Caregiver.
  • Please enter a second contact number for the Parent/Primary Caregiver, if applicable.
  • Please describe the best way to contact the parent / caregiver, e.g. text, phone & leave message, text then phone.
  • Please identify the relationship between the Partner and the Baby/Child e.g. Father, Mother, Step-parent, current Partner.
  • Please complete only if the Partner does NOT live with the baby / child.
  • Please enter the Partner's date of birth, if known.
    DD slash MM slash YYYY
  • Please select the primary ethnicity for the Partner, if known. Use the next field for secondary ethnicity.
  • Please select the seondary ethnicity for the Partner, if known.
  • Please enter the Iwi of the Partner, if applicable.
  • Please enter the date of birth of the Baby/Child, or Expected Date of Delivery of the Baby.
    DD slash MM slash YYYY
  • Please select the gender of the Baby/Child.
  • Please select the primary ethnicity for the Baby/Child. Use the next field for secondary ethnicity.
  • Please select the secondary ethnicity for the Baby/Child.
  • Please enter the Iwi of the Baby/Child, if applicable.
  • Please enter the details of other dependants living at the same address as the Baby/Child.
    Name:Sex: (M/F)DOB: (dd/mm/yy) 
  • GP (General Practitioner)LMC (Lead Maternity Carer)NHI NumberWell Child Provider
  • Name:Contact Details: 
  • The criteria in List A are the main criteria for Family Start; the main situations where Family Start assistance is targeted. Please select as many of these criteria from the categories below that apply as the reason(s) for your referral. The categories are; mental health issues, addiction problems; childhood history of abuse; care or protection history; relationship problems; parenting & development issues; young parents (under 18) experiencing additional challenges/needs. For more information on the Family Start Referral Criteria, please refer to the Family Start Service Overview provided by Family Works South Canterbury.
  • Either parent/caregiver has a mental health problem - please select all that apply.
  • Please specify any other mental health issues.
  • Either parent/caregiver has a problem with any of the following - please select all that apply.
  • Please specify any other addiction problems.
  • Please select if applicable.
  • Please select all that apply.
  • Evidence of relationship problems including any of the following - please select all that apply.
  • Please select all that apply.
  • Please add any comments relevant to the List A Referral Criteria.
  • The criteria in List B are additional circumstances where a family / whanau may still met the criteria. The family / whānau will need to be experiencing challenges in two or three of these areas to be referred. The categories are; Sudden Unexplained Death Indicators (SUDI); multiple births; lack of positive support networks; criminal justice involvement; financial & material resource difficulties; frequent change of address; low parent education. For more information on the Family Start Referral Criteria, please refer to the Family Start Service Overview provided by Family Works South Canterbury.
  • Please select all that apply.
  • Please select all that apply.
  • Please select all that apply.
  • Please select all that apply.
  • Please select all that apply.
  • Please add any comments relevant to the List B Referral Criteria.
  • Please identify any safety concerns that the Family Start Team should be aware of. If other, please specify in the field below.
  • Please enter details.
  • Please add any additional comments relating to this referral.
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