Referral Form for Child & Adolescent Wellbeing Services

Gender(Required)
Do all legal guardians agree to the child receiving therapy?(Required)
Cost(Required)
Our minimum fee is $20 per session (upon application for subsidy). Please email contact@homeandfamily.net.nz if you would like more info on our fee structure.

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 PO BOX 287 Christchurch e: contact@homeandfamily.net.nz web: www.homeandfamily.net.nz