Te Oriori Referral Form Te Oriori Referral Form Step 1 of 6 0% Referral Type:* Self referral Whānau member referral Agency/Professional referral Referrer Name:* First Last Contact Phone Number:*Email:* Agency Name (if applicable):*Please state your relationship to the parent/caregiver you are making this referral for:*The parent/caregiver has agreed to this referral being made.* Yes Parent/Caregiver DetailsParent/Caregiver Name:* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity/Iwi:Gender: Female Male Other NHI (only if known):GP / Medical Centre:Contact DetailsAddress: Street Address Address Line 2 ZIP / Postal Code Contact Phone Number:*Email: Tamariki DetailsPlease complete this section for any children who will attend Te Oriori programmes.Child 1 Name: First Last Date of Birth: Date Format: DD slash MM slash YYYY Ethnicity / Iwi:Gender: Male Female Child 2 Name: First Last Date of Birth:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity / Iwi:Gender: Male Female Child 3 Name: First Last Date of Birth:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity / Iwi:Gender: Male Female Child 4 Name: First Last Date of Birth:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity / Iwi:Gender: Male Female Emergency ContactName: First Last Contact Phone Number:Relationship to the parent/caregiver:e.g. partner, mother etc Further InformationCurrent support/interventions needed:*Existing supports/interventions (including any other services/professionals involved):*Previous supports/interventions (including any other services/professionals involved):*Current status with Oranga Tamariki:*Any other relevant information:*What support do you think this whānau needs?Are you aware of any previous or existing support/interventions for this whānau, such as the involvement of any other services/professionals? (If yes, please provide any further details if you can.)How can we support you and your whānau?Are you currently receiving support from any other services/professionals? (If yes, please provide further details if you can.)Is there anything else you would like us to know?Please select the programme(s) you are interested in attending: Mana Reo (Tuesday Te Reo Māori class) Whare Tākaro (Wednesday Playgroup) Toi Mauri Tau (Thursday small group based around attachment) Awesome Whānau (Friday Parenting Course) Te Hā WaitahaAre you and your whānau smoke free?YesNoAre you (or your whānau) interested in support from us to become smoke free?Yes - I would like to be contacted by a Stop Smoking Practitioner.NoTo help us improve our service, can you tell us more about why you have selected 'No'?Is the parent/caregiver/whānau smoke free?YesNoUnsureIs the parent/caregiver/whānau interested in support from us to become smoke free?Yes - They would like to be contacted by a Stop Smoking Practitioner.NoUnsure - They may like to be contacted by a Stop Smoking Practitioner.To help us improve our service, can you please tell us more about why you said "No"? Consent I give my consent that information may be shared with other staff of Purapura Whetu for the purposes of my participation in Te Oriori if required.Photographs I agree that any photographs, videos taken during the activities may be used for promotional purposes in connection with future activities similar to these including on the website and in advertising material.
