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

Referral Form for Child & Adolescent Wellbeing Services

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

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 parent or caregiver.

Cost per session

Psychologist – $185

CBT Therapist – $95

Kaiārahi – Cost on application

Subsidy available

Home & Family are a Charitable Trust and we aim to provide affordable therapy services. A subsidy may be offered by completing the Subsidy Application Form, which you will receive upon the acceptance of your referral.


Do all legal guardians agree to the child receiving therapy?(Required)
Our Fees(Required)
The fee structure can be found on the left of the page you are currently on.

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: [email protected] web: