WHĀNAU REFERRAL/INTAKE FORM

PERSONAL DETAILS	REFERRAL DATE:
First Name	Gender	M	F	Gender Diverse
Middle Initial
Last Name	Date of Birth
ADDRESS DETAILS
Home Address	Home Phone
Mobile Phone
Work Phone
(This number will be added to your file as contactable)
Email	(This will be added to your file as contactable)
WHAKAPAPA	DOCTOR
Ethnicity	Doctor
Iwi	Clinic
Hapu	Phone
ADDITIONAL DETAILS FOR TAMARIKI/RANGATAHI
Contact Details for	Mother Father Guardian
Name	Home Phone
Address	Mobile Phone
Work Phone
EMERGENCY CONTACT
Name	Relationship
Home Phone	Mobile Phone
Comments
REFERRAL DETAILS (complete if referred from an agency)
Referral Date	Work Phone
Referral Source	Agency Self Whanau	Mobile Phone
Contact Person	Email
Are there children currently in your care?	Unknown Yes No	Are you currently involved with other agencies? If yes, please indicate. Yes _____________________________________________________________ No
How did you hear about us?
Referral received by

REASON FOR REFERRAL
(Please state the reason(s) you are wanting to come to Āwhina Whānau Services and what you hope to gain)
PRESENT CIRCUMSTANCES – *include any children in your care, name and date of birth
(Living circumstances, employment, schooling, support networks etc)
RISK ASSESSMENT (KESSLER) – In the last two weeks how often did you feel? (please circle)
Rating Scale	None	Little	Some	Most	All
So sad nothing could cheer you up	0	1	2	3	4
Worried or frightened?	0	1	2	3	4
Restless or stressed?	0	1	2	3	4
Hopeless?	0	1	2	3	4
That everything was an effort?	0	1	2	3	4
Worthless?	0	1	2	3	4
Assessment (please tick if applicable)
High anxiety High fear state Financial issues Accommodation Depression Grief/loss Clinical condition (please state) ___________________	Low appetite Suicidal ideation Intent to harm: High / Low / Plan (circle) Self-harm Low mental health Alcohol issues Drug issues Emotion regulation issues	Relationship issues Safety issues Domestic violence Family violence Sexual abuse/harm Psychological/emotional abuse Historical trauma Sleep disturbances Mood swings (highs/lows)	Lack of support Social stressors Esteem issues Environment issues Health issues Physical issues OTHER (please state) ____________________ ____________________
OFFICE USE ONLY
Score ________	Priority: Low Med High	DATE INITIAL
SHCSS SHCS CY FVRESP CS FW YJ FW YDP TAT LC AWS OTHER	Counselling &/or Social Work Piringa Whānau Police Diversion Tamariki Kaha Programme Te Ara Totika – Rangatahi Resilience Programme Te Rito o te Whānau Youth Development Programme Youth Justice Other (please note) _____________________________________________	Referral Received:
Entered into Exess:
Allocated to Waharoa:
Waharoa Completed:
Allocated by :
Allocated to: (name):