• Kahukura Aroha (Intensive Family Wraparound) Service Referral

  • Child and Family Information

  • Date of Birth*
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    2 digit day, 2 digit month, 4 digit year
  • Ethnicity*

  • Interpreter or Communication aide required?*
  • Does the child know about this referral?*
  • Number of Household’s Child currently resides in:*
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  • Is it OK to use this email address for communications and notifications?

  • School Information

  • Is the child currently attending school?*
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  • Has the child had a B4 School Check completed?
  • Does the School know about this referral?*

  • Details of all people living at child’s address

    Please include other children and note if the person is a Legal Guardian
  • People who live at the child's address*
    Rows

  • Other Significant People NOT living with the child

    Please include other children but exclude service providers
  • Other significant people who do not live with the child
    Rows

  • If the legal guardian does not live at the child’s address, please provide the contact details of all legal guardians as we are required to advise all legal guardians of our service involvement with the child.

  • Legal Guardian(s) not living at child's address
    Rows

  • Referral Agency Information

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  • Lead Agency for Family*
  • As the referring agent, I can confirm the parent/caregiver(s) has provided verbal consent to sending this referral to Stand Tū Māia*
  • If the Child lives with caregivers, do they receive Permanent Caregiver Support?*
  • Response urgency*
  • Child Safety Risk*
  • Any current Care and Protection Concerns?*
  • Is the child known to Oranga Tamariki ?*
  • Other Agencies/services Currently Involved

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  • Child and Adolescent Trauma Screen

  • Being “trauma-informed” matters to Stand Tu Maia. The idea behind trauma-informed services is pretty straightforward: When the approach we provide to children and families is informed by a basic knowledge of “what stressful or scary events have happened to them” and how these traumatic experiences and associated stress have impacted on them, many things are likely to turn out better.

    Stressful or scary events happen to many children. Below is a list of stressful and scary events that sometimes happen. Mark YES if any of these events have happened to the child to the best of your knowledge. Mark NO if the child has not experienced these events to the best of your knowledge.

  • Serious natural disaster like a flood, tornado, hurricane, earthquake, or fire.*
  • Serious accident or injury like a car/bike crash, dog bite, sports injury.*
  • Robbed by threat, force or weapon.*
  • Slapped, punched, or beat up by someone in the family.*
  • Slapped, punched, or beat up by someone not in the family.*
  • Seeing someone in the family get slapped, punched or beat up.*
  • Seeing someone in the community get slapped, punched or beat up.*
  • Someone older touching their private parts when they shouldn’t*
  • Someone forcing or pressuring sex, or when they couldn’t say no.*
  • Someone close to the child dying suddenly or violently.*
  • Attacked, stabbed, shot at or hurt badly.*
  • Seeing someone attacked, stabbed, shot at, hurt badly or killed*
  • Stressful or scary medical procedure.*
  • Being Around War.*
  • Other stressful or scary event*

  • Access Criteria Information

    To be completed by Referral Agent together with the Parent/Caregiver(s).

  • Please tick all the areas relevant to the current difficulties this child and family are experiencing:

  • Child
  • Parent/Caregiver
  • Family Environment
  • School
  • Community

  • Child and Family Protective Factors

    Please tick which (if any) of the 4 protective factors exist for this child and family. Please select whether you consider the protective factor to be strong or not so strong

  • Caring and Support Strong

    Refers to family bonding and social factors such as strong relationships with other family members, teachers and other significant people who can demonstrate to children positive attitudes and behaviours

  • Caring and Support*

  • High expectations

    Refers to family beliefs and standards that help the child make the connections between behaviours and consequences

  • High Expectations*

  • Opportunities for Participation

    Refers to whether the child has strong interests outside the family or strong attachment with confiding adult outside their immediate family

  • Opportunities for Participation*

  • Temperament and Behaviour

    Refers to the child’s individual characteristics such as cognitive skills, strong coping skills, high self esteem, and temperament

  • Temperament and Behaviour*

  • Behaviour and Health Checklist for Parents/Caregivers Part 1

    The following behaviours are sometimes seen in children who have problems at home or at school. Please tick in the box provided those that apply to your child.
  • Does Your Child Often Lose Their Temper?*
  • Does Your Child Often Argue with Adults?*
  • Does Your Child Often Defy or refuse adult requests or rules?*
  • Does Your Child Often deliberately do things to annoy people?*
  • Does Your Child Often blame others for own mistakes?*
  • Does Your Child Often get touchy or annoyed by others?*
  • Does Your Child Often seem angry or resentful?*
  • Does Your Child Often act spitefully or vindictively?*
  • Does Your Child Often swear or use obscene language?*
  • Does Your Child Often lie?*
  • Does Your Child Often skip school?*
  • Does Your Child Often initiate physical fights?*

  • Behaviour and Health Checklist for Parents/Caregivers Part 2

    The following behaviours are sometimes seen in children who have problems at home or at school.Please tick in the box provided those that apply to your child.
  • Has Your Child run away from home?*
  • Has Your Child run away from class?*
  • Has Your Child run away from school?*
  • Has Your Child been stood down from school?*
  • Has Your Child broken into someone's house or car?*
  • Has Your Child deliberately destroyed someone's property?*
  • Has Your Child deliberately destroyed their own property?*
  • Has Your Child been physically cruel to animals?*
  • Has Your Child been physically cruel to people?*
  • Has Your Child used a weapon in more than ONE fight?*
  • Has Your Child deliberately set fires?*
  • Has Your Child deliberately stolen?*
  • Has Your Child displayed inappropriate sexualised behaviour?*

  • Health Information

  • Has the child been diagnosed as having any of the following Physical conditions?*

  • Currently taking any medication relating to a Physical condition - if yes please list below
    Rows
  • Has the child been diagnosed as having any of the following Mental conditions?*

  • Currently taking any medication relating to a Mental condition - if yes please list below
    Rows
  • Has the child been diagnosed as having any of the following Developmental conditions?*

  • Currently taking any medication relating to a Developmental condition - if yes please list below
    Rows

  • Expectations of this referral to Stand Tū Māia

  • Child Expectations - Which of the following 5 items best describe what you the child hope to achieve?
  • Parent/Caregiver Expectations - Which of the following 5 items best describe what you the parent(s)/caregiver(s) hope to achieve?*
  • Referral Agency Expectations - Which of the following 5 items best describe what you hope the child and family will achieve?*

  • Consent to Referral

  • I/we agree to our child and family referral to Stand Tū Māia*
  • I/we understand that this referral, if accepted, will lead to an assessment of our child and family’s needs and an agreed response, which may or may not include agreeing to a child and family plan to receive a range of services to support our family goals*
  • I/we give permission for Stand Tū Māia staff to document and gather information for the purpose of undertaking an assessment.*
  • I/we give my consent for our child and family to participate in follow up evaluation for the purpose of improving service delivery.*
  • I/we give my consent for our child and family information being used (without identifying our child or our family) for the purpose of reporting, reviewing and evaluating Stand Tū Māia and for contribution to research that supports best practice.*
  • IMPORTANT: Is there any reason why any of the legal guardians should not be advised of our involvement in this referral? e.g. FV, refuge involved, court case pending but no legal proceedings finalised.*

  • Please click PREVIEW to check your form.

    You MUST CLICK SUBMIT for the form to be processed

    You will receive a confirmation email when your referral has been accepted into the forms system in preparation for distribution to your site of choice. If you don't receive this confirmation, please email referrals@standforchildren.org.nz 

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