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Family Start Referral Form

Submit this form to request a place for your child/children in our Family start program, or

Click here to download application form.

Referral Agency Details:

Name of Person:

Position of Referral Person & Agency:

Physical/Postal Address:

Phone:

Mobile:

Email:

Consent from Family for Referral:

• Yes
• No

Date of Referral:

Mothers Details:

Full Name & Relationship to Baby:

Full Physical Address:

Phone:

Mobile:

Age:

Date of Birth:

Ethnicity:

Partners Details (optional):

Full Name & Relationship to Baby:

Full Address:

Phone Number:

Date of Birth:

Age/Ethnicity:

Babys Details:

Full Name of Baby:

Date of Birth or Expected Date of Birth:

Ethnicity:

Gender:

• Male
• Female

Other Children in the Family:

Full Name(s) and Date(s) of Birth:

Reason for Referral, Please indicate how much support is required in the following areas 1=Low Needs, 5= High Needs:

Unsupported Parent (care-giving parent is a sole parent bringing up the child In the absence of a cohabiting partner or other significant Parental or whanau support):

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No or minimal ante-natal care (No, or late, ante-natal care i.e. after six months of pregnancy):

12345

Young mother (Mother is younger than 18 years):

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Mental ill health (Either parent has a current mental health problem including:post-natal depression, any other type of depression, either parent has any history of mental health problems):

12345

Substance Abuse (Caregiver or partner consider either one has a problem with alcohol or illicit drug use):

12345

Family history of abuse (Caregiver abused as a child, Caregiver’s partner abused as a child, Problem of abuse or neglect of previous children in family):

12345

Relationship problems(Evidence of any significant relationship problems, Difficulties with partner. e.g. family violence, conflict, lack of support):

12345

Low income status (Evidence of low income e.g. receipt of income support or low wages):

12345

Lack of essental resources (One or more of the following applies: Family’s housing situation is unstable or unsuitable for their current needs e.g. serious lack of space, insecure tenure. Lack of access to a telephone or transport. Lack of basic amenitie

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Frequent change of address (Caregiver has changed address more than twice in the last 12 months):

12345

Low maternal educational qualifications (Mother left school without any formal educational qualifications. Mother still lacks qualifications, e.g. not one School Certificate or National Certificate of Educational Achievement subject gained):

12345

SIDS factors (Not covered by the above, one or more of the following factors apply: Mother smoked while she was pregnant. Baby has not been breast-fed, or has only been breast-fed for a short period. Mother experienced difficulty in establishing succes

12345

CYFS Involvement (Family has had Child Youth and Family Services involvement in the past):

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