Referral Copy

Kirikiriroa Family Services Trust (KFST) delivers free, home-based support services for all whānau in Waikato and Waipa.

Support/services you can refer to:

Te Haumirimiri Ngākau Mokopuna

By clicking the submit button at the end, the whānau being referred consent to Kirikiriroa Family Services Trust receiving this information and then contacting you to discuss what services/supports the whānau require. All information entered below will be kept confidential by Kirikiriroa Family Services Trust and used for the sole purpose of assessing the suitability of referrals.

Please select the service you believe is required form the options below:

Te Haumirimiri Ngākau Mokopuna

Tell us about you

You can refer yourself to KFST services, or a professional/practitioner can refer on your behalf. You can include more than one child per referral. Please ensure to include all details for each Child.

Your name / Referrer name*

Your relationship to child / Your agency name / Your role*

Your contact phone*

Your contact email*

Type of referral*

Self referral - You are referring yourself

Professional / Practitioner

Other

Tamaiti / Child Details

Please provide all four details for each child you are referring.

Name of Tamiti / Child*

Child's date of birth

Check “Unborn” if you are expecting only

Unborn?

Gender

Ethnicity

Please provide the details for any additional tamariki/children in the home, if they are also considered a referral:

Additional Tamariki details

Additional Tamariki/Child

Name of Tamariki/Child

Child's date of birth

Gender

Ethnicity

Include in referral

Add Tamariki

Whānau Address*

Caregiver details - please provide the details below for the caregiver/parent:

Full Name*

Contact Phone Number*

Contact Email*

Relationship to the child*

Date of birth*

Add additional caregiver

Additional Caregiver

Full Name

Contact Phone Number

Contact Email

Relationship to the child

Date of birth

Lives at the same Whanau Address

Address

How can we help?

Please tick all options that relate to the tamariki / child or to the parent / caregiver of the tamariki you are refering. The more details you provide us the better able we are to find you appropriate support.

Additional information

Current supports and services involved (Provide contact details of key work).

What further services/supports are needed?

Current whānau situation / worries

Consent / Submit Referral

Please check your contact details are correct below so that someone from KFST can contact you to discuss your referral

Your name / Referrer name

Name

Your relationship to child/ Your agency name/ Your role

Relationship

Your contact phone

Contact phone

Your contact email

Email

Whānau Address

Address

By clicking Submit below you consent to Kirikiriroa Family Services Trust receiving your information and contacting you. you will also be emailed a copy of your referral form.

Ngā mihi nui. Thank you for your patience and effort in making a referral.

Referral

Kirikiriroa Family Services Trust (KFST) Referral Form