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.

Cost Information:

Home & Family are a Charitable Trust and we aim to provide affordable therapy services. Our subsidy 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.

Child's Name(Required)

Gender(Required)

She/Her

He/Him

They/Them/Their

Address(Required)

Date of Birth(Required)

Ethnicity(Required)

Iwi (if applicable)

Do all legal guardians agree to the child receiving therapy?(Required)

Yes

Our Fees(Required)

I have read and understood our fee structure (see left)

The fee structure can be found on the left of the page you are currently on.

Primary Caregiver/Parent Name(Required)

Relationship to Child(Required)

Address(Required)

Contact Number(Required)

Email Address(Required)

Gender

Other Caregiver/Parent Name(Required)

Relationship to Child(Required)

Address(Required)

Contact Number(Required)

Email Address(Required)

Gender

Referral Details

Referrer Name(Required)

Agency(Required)

Contact Number(Required)

Email Address(Required)

Have you informed the client the referral has been made?(Required)

Yes

Please indicate issues/concerns:(Required)

Sleep

Aggression/Violence/Outbursts

Mood

Possible trauma history/event

Anxiety

Suicidal Thoughts

Reason for referral:(Required)

Describe difficulties at home:(Required)

Describe difficulties at school:(Required)

Legal Orders in Place

Custody Orders(Required)

Yes

Parenting Orders(Required)

Yes

Court Appointed Access(Required)

Yes

Protection Orders(Required)

Yes

Trespass Orders(Required)

Yes

Other (Please Specify)

Any safety or legal issues?:(Required)

Is the Whānau currently involved with Oranga Tamariki?(Required)

Yes

Has the Whānau previously been involved with Oranga Tamariki?(Required)

Yes

Has the Whānau experienced family violence?(Required)

Yes

Alcohol or substance abuse?(Required)

Yes

Are there concerns regarding mental health for the Whānau?(Required)

Yes

Parenting concerns?(Required)

Yes

Has the Whānau used Home & Family services in the past?(Required)

Yes

Other Whānau / Caregivers / Professionals / Agencies Involved:

List below (please include a contact name, agency name and contact number):

Home & Family Charitable Trust PO BOX 287 Christchurch e: [email protected] web: www.homeandfamily.net.nz