IFWS - Kakahu 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*

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

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

Referral Agency Information
Referral agent name*

First NameLast Name
Agent Role*
Agency*
Agency Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Agency Postal Address (if different)

PB Box/Private Bag

CityState / Province

Post Code
Agency Phone number

Area CodePhone Number
Referral Agent Mobile

PrefixPhone Number
Referral agent email*

Confirmation EmailA copy of the filled form will be sent to this address so please enter twice to confirm accuracy
Lead Agency for Family*

YesNoUnsure
Which Stand Tū Māia Region are you referring this child to?*
Reason for Referral*
Please specify why this child and family require support from Stand Tū Māia.
As the referring agent, I can confirm the parent/caregiver(s) has provided verbal consent to sending this referral to Stand Tū Māia*

YesNo
Parent/Caregiver Name

First NameLast Name
Parent/Caregiver Name

First NameLast Name

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*

StrongNot so strong
High expectations

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

StrongNot so strong
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*

StrongNot so strong
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*

StrongNot so strong

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:

Intensive Family Wrap Around Service Referral

	Medication:	For which condition e.g. Asthma
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	Medication:	For which condition e.g. Anxiety Disorder
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	Medication:	For which condition e.g. Autism Spectrum Disorder
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