• Kahukura Whānau (Family Therapy) Service Referral

    Referral Information for Kahukura Whānau

  • Tēnā Koutou, Tālofa Lava, Kia Orana, Fakaalofa Lahi Atu, Malo e Lelei, Bula Vinaka, Taloha Ni, Warm Greetings to our referral agents and agencies.

    Stand Tū Māia is a charity that provides the Stand for Children Service – a nationwide intensive wraparound social service including therapeutic care and education, for vulnerable children aged 5 to 12 and their families. Stand Tū Māia also have a long history of providing Social Workers in Schools Services.

    Stand Tū Māia also offers a Family Therapy Service in our Midland, Central and Christchurch Regions. The focus of the service is to provide a response to protect the most vulnerable children/young people aged 0 to 17 years of age (including unborns) from further maltreatment/exposure to chronic trauma, and to support their recovery from that exposure and enhance their wellbeing.

    The Family Therapy Service is child focused and structured to achieve a reduction in risk and an increase in protection for children and young people through a therapeutic and multi-systemic approach to change within the family/whānau, school and community through the provision of a Family Therapy Service.

    The Family Therapy Service is “trauma informed” meaning that its delivery is grounded in an understanding and responsiveness to the impact of trauma that emphasises physical, psychological and emotional safety for Children and families.

    The service will create an opportunity for them to rebuild a sense of control and empowerment and the focus on supporting positive family functioning will help address and support resilience and recovery from damaging experiences such as those associated with intergenerational trauma, family violence, parental depression and chronic health issues, grief and loss, and addiction lifestyles.

    If you know children and families with these kinds of struggles then perhaps our Family Therapy Service can help. These children and their families need us to work together if they are to heal and recover.

    For each child and family we seek to develop their capacity to live in healthy, hopeful relationships with others and function as a stable, capable and loving family. On this depends all of the other necessary outcomes which contribute to their ability to enjoy life and reach their potential. This provision of profoundly healing relationships is at the heart of the theoretical underpinning of Stand Tū Māia so we expect when you refer to us that you will continue your involvement with the child and family, working to your strengths as we work to ours. 

     

    Referrals for Stand Tū Māia Family Therapy Services

    Access to our family therapy service is limited to:

    • vulnerable families with children aged 0 to 17 (including unborns),
    • is by referral only from professionals such as;
      • Oranga Tamariki (Ministry of Vulnerable Children)
      • RTLB
      • Learning Support
      • Child and Adolescent Mental Health Services (CAMHS)
      • Social Service NGO’s

    Priority will be given to Oranga Tamariki and CAMHS referrals.

    Acceptance into the service will be based on referral agents completing our Stand Tū Māia Family Therapy Service Referral Form which will demonstrate that the child and family meet the access criteria and have consented to receive family therapy services from Stand Tū Māia.

     

    Privacy Act

    To comply with the Privacy Act 1993, we must take such steps as are, in the circumstances, reasonable to ensure that children and families are aware of how their information will be managed.

    1. The purposes for collection of information by Stand Tū Māia  are:

    a) To determine if a child and family meet the access criteria for services and to assist with the assessment of child and family needs and the development of child and family plans.

    b) For statistical purposes which do not reveal any child’s identity.

    2. When a referral agency is submitting this application on the child and family’s behalf andintend retaining a copy of this information, or any subsequent information received, the family must also be advised of that by the referral agency.

    3. The supply of information is completely voluntary. However, the consequence of non-supply could result in delayed access or non-entry of the family to Stand Tū Māia.

    4. Children and families are entitled access to, and correction of, any personal information held by Stand Tū Māia.

    5. Children and families understand their rights and responsibilities.

    6. Children and families are aware of the complaints process if dissatisfied with any aspect of Stand Tū Māia.

    7. Children and families are aware that completing an application does not guarantee access to Stand Tū Māia.

    Any information used for reporting purposes is in a non-identifiable statistics format only.

     

    Completing the Referral

     

    It is vital that all fields are completed fully and the consent page is signed. If the consent is not signed we will be required to return the form to the referrer to complete before we can process the referral.

    If information is missing or unclear this may also delay our ability to proceed with the referral acceptance process and will result in us coming back to you as the referrer for further clarification.

    Once processed, we will advise if the referral has been accepted and outline the next steps and timeframes for our family therapy service response.

    We thank you for your referral, appreciate the time you have invested in making this referral and look forward to our continued collaboration in supporting our most vulnerable children and families.

     

    If you would like any assistance with the form or have any questions please do not hesitate to contact us.

     


    Should you wish to follow up on a referral or provide important information, please contact us via referrals@standtumaia.nz

  • Child/Young Person and Family Information

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

  • Interpreter or Communication aide required?*
  • Does the child/young person know about this referral?*
  • Number of Household’s Child/Young Person currently resides in:*
  •  -
  •  -

  •
  • Is it OK to use this email address for communications and notifications?

  • School Information

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

  • Details of all people living at child/young person’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/young person

    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/young person’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/young person.

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

  • Referral Agency Information

  •  -
  •  -

  •
  • 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/young person lives with caregivers, do they receive Permanent Caregiver Support?*
  • Response urgency*
  • Child/Young Person Safety Risk*
  • Any current Care and Protection Concerns?*
  • Is the child/young person known to Oranga Tamariki ?*
  • Other Agencies/services Currently Involved

  • Browse Files
    Cancelof

  • 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 members of this family are experiencing:

  • Child/Young Person difficulties
  • Parent/Caregiver difficulties
  • Family Environment difficulties
  • School difficulties
  • Community difficulties

  • Children/Young Persons and Family Protective Factors

    Please tick which (if any) of the 4 protective factors exist for the children/young persons 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/young people positive attitudes and behaviours

  • Caring and Support*

  • High expectations

    Refers to family beliefs and standards that help a child/young person make the connections between behaviours and consequences

  • High Expectations*

  • Opportunities for Participation

    Refers to whether the child/young person 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/young person’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/young people 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/young people 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/young person 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/young person 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/young person 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/Young Person Expectations - Which of the following 5 items best describe what you 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 

     

  •  
  • Should be Empty: