Tohutoro

Kirikiriroa Family Services Trust (KFST) Referral Form

Nau mai haere mai,
Kia ora, ko whero toku ignoa and I will be here to awhi you through your referral.

Tell us about yourself

Name*

Role*

Agency name*

Email for confirmation*

Mobile*

Tell us about the hapū māmā, tamariki or rangatahi

Name of caregiver*

Relationship to the child*

Caregiver date of birth*

Email

Mobile*

Address for visit*

Name of tamariki / rangatahi*

Date of Birth of tamariki / rangatahi

Gender*

Ethnicity*

Other ethnicity

Additional Tamariki/Child

Name of Tamariki/Child

Child's date of birth

Gender*

Ethnicity

Other ethnicity

Add Tamariki

How can we help?

Hauora
(Mental health, Addictions, Disability, Self Harm, Behavioural, Trauma)

Social
(Housing, Family Harm, Identity - Rainbow, limited supports)

Cultural
(Connection to Identity, whānau, whakapapa, whenua, te Ao Maori)

Care and Protection
(Neglect, Abuse – Physical, Mental, Emotional, Sexual; Harm; Safety)

Education
(Early Childhood support, alternative, school engagement)

Justice
(youth justice, Police involvement)

Referral support for the whānau

Parenting Support
(Gang Affiliation, Support, Young Parents, Shared, Relationship Breakdown, Unemployment, Financial)

Tell us more*

Nga mihi,
We know how valuable your information is and appreciate the time you have taken to complete this form.
By submitting your information you give us the consent to make contact with you.
All information provided will be kept confidential by KFST and used for the sole purpose of assisting you to appropriate supports.

Thank you! Your submission has been received!

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Call Us To Refer

You can also contact us direct and we can receive referrals over the phone.

Contact Us