Social Workers in Schools Referral Form

Click here to download the form.

Date of Referral

Student Details

Students Name:

Date of Birth & Place:

Age:

Sex:

Male
Female

Ethnicity:

Parent /Caregiver Name(s)

Address:

Home Phone:

Mobile:

Email:

Occupation:

Other Signicant Family Members(name/relationships/contact phone if applicable)

Referrer Contact Details

Referred by:

School
Agency
Relative/Friend
Other

Referrer Name:

Agency:

Position:

Branch:

Work Phone:

Work Fax:

Email:

Mobile:

Reason for Referral:

Referrer Assessment (based on the above referral please read and tick appropriate box)

HIGH (Current crisis for child/families – family breakdown, suspension from school, a serious medical situation (CYFS Notification, domestic violence and abuse added))

MEDIUM (Ongoing issues (less serious) e.g. repeated truanting, constant bullying of other children getting into fights (frequently) recurring health problems)

LOW (Single instance of concern. Early intervention is undertaken to avoid escalation. Single incident of truancy or bullying occasional incidents of coming to school inadequately clothed or without lunch)

Worker Saftey Issues (violent behaviours, aggressive dogs, firearms, gang affiliations etc...)

If yes, please elaborate:

Student/Family Needs/Issues to be Addressed

(include details of any previous or current interventions):

Student/Whanau Consent (Have you discussed this referral with the student or whanau concerned?)

Student

Whanau

Family Services

Child Psychotherapy Services Counselling Services Counselling in Schools Granger Grove Mellow Parenting

Early Childhood Education Services

St George's Preschool St Mary's Preschool Foundations for Learning Hippy

Social Work Services

Family Start Social Workers in Schools

Donations

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