Child Therapy Referral Form - Home & Family - Te Whare Manaaki Tangata - Child, Youth and Parenting Support Services

Referral Form for Child Therapy

Your referral and any subsequent contact will be confidential in order to protect your privacy. Information about our Privacy Policy is available upon request.

Our Fees:

Home & Family are a Charitable Trust and we aim to provide affordable therapy services. We have a subsidy available that allows for our clients to pay our minimum fee of $20.00 per session. The subsidy application form will be provided upon the acceptance of your referral.

Many referred clients are supported by student counsellors at Home & Family. They automatically receive the full subsidy and are typically seen sooner due to shorter waitlists.

 

NOTE: A session may be in the form of initial consultation either by phone or face to face, or a 1-hour individual session at our offices, or at an agreed location like school or home. Individual sessions are 50 minutes, plus 10 minutes of feedback with caregiver/parent.

Do all legal guardians agree to the child receiving therapy?(Required)
Our Fees(Required)
Our fee info can be found on the page you are currently on (see left or scroll to view).

Referral Details

Have you informed the client the referral has been made?(Required)
Please indicate issues/concerns:(Required)

Legal Orders in Place

Custody Orders(Required)
Parenting Orders(Required)
Court Appointed Access(Required)
Protection Orders(Required)
Trespass Orders(Required)
Is the Whānau currently involved with Oranga Tamariki?(Required)
Has the Whānau previously been involved with Oranga Tamariki?(Required)
Has the Whānau experienced family violence?(Required)
Alcohol or substance abuse?(Required)
Are there concerns regarding mental health for the Whānau?(Required)
Parenting concerns?(Required)
Has the Whānau used Home & Family services in the past?(Required)

Other Whānau / Caregivers / Professionals / Agencies Involved:

Home & Family Charitable Trust 41 Opawa Road, Christchurch 8023 e: [email protected] web: www.homeandfamily.net.nz