Diversity Counselling New Zealand (DCNZ)- Eco project series

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 Korowai Tauawhi - Family Start(early Intervention for whānau with pre-school tamariki)
Kāinga Rua (transitional housing)
Poipoia Te Mokopuna (ECE Support)
Te Waka Tamariki (collaborative approach with whānau & tamariki up to 18 years)
Tiakina Te Rito Rangatahi (Youth Support)

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 Korowai Tauawhi (Family Start) - early Intervention for whānau with pre-school tamariki

Kāinga Rua - rawakore (extreme poverty) or kāinga kore (homeless)

Poipoia Te Mokopuna - early childhood focus with te Ao Māori perspectives

Te Waka Tamariki - collaborative approach with whānau & tamariki up to 18 years

Tiakina Te Rito Rangatahi (Youth Support)

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*

Agency's Name

Agency's Role

Your contact phone*

Your contact email*

Type of referral*

Self referral - You are referring yourself

Professional / Practitioner

Other

Is the whānau aware of this referral and have they given their consent for this referral?*

Yes

No

Unfortunately we're not able to proceed with this referral unless we have whanau consent. Please seek consent from the whanau before making a referral.

Tamaiti / Child Details

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

Name of Tamaiti / Child*

Child's date of birth

Check “Unborn” if you are expecting only

Unborn?

Gender

Ethnicity

Other 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

Other Ethnicity

Include in referral

Lives at the same Whanau Address

Address

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

Agency's Name

N.A.

Agency's Role

N.A.

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.

Rauemi

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Kirikiriroa Family Services Trust (KFST) Referral Form