External Agency Referral Form

Thank you for choosing to make a referral to Family Works.

Your information is important and helpful to us. 

All information obtained will remain confidential. 

Please complete the form with as much detail as possible. Fields marked with an * are compulsory. 

 

Primary Contact Person
Clients preferred way of contact
All clients go through an assessment process to determine the best service. Please include here what service you believe will assist the familiy, if known.
Please attach a copy of any relevant assessment, reports or any additional information to support this referral with client consent
Any concerns regarding the safety of the client or client's family e.g. child/young person
Family violence or partner violence issues
Concerns re mental health (Issues of risk or self-harm)
Orders
Alcohol / Drug issues
Any known risks affecting a staff member working with this client / family in their home e.g. dogs, gang involvement, family violence, environmental ?
Oranga Tamariki Involvement
If yes to Oranga Tamariki Involvement
Before submitting this referral it is important that the individual / family being referred has been consulted and has given their consent.
Please provide your contact details