Self Referral for Assessment This form is to be completed by a family/whānau member seeking self referral for their family/whānau. Self Referral Step 1 of 9 - Date of Referral 11% Date of Referral Day Month YYYY Have you or your family/whānau had any previous involvement with Early Start? Yes No Mother's DetailsMother's Name First Name Last Name Mother's NHI Mother's Date of Birth Day Month Year Mother's AddressMother's Email Mother's Mobile PhoneMother's Ethnicity Mother's First Language Father's DetailsFather's Name First Name Last Name Father's NHI Father's Date of Birth Day Month Year Father's AddressFather's Email Father's Mobile PhoneFather's Ethnicity Father's First Language Baby's DetailsBaby's Name First Name Last Name Baby's Date of Birth Day Month Year Baby's Age Baby's Gender Male Female Baby's Ethnicity If currently pregnantPlease list the expected date of birth. Day Month YYYY Other Children in the FamilyAre there other children in the family? Yes No Other ChildrenClick on the + button to add more children.NameGenderEthnicityDate of BirthAddress if Different Add Remove Entry CriteriaFamily ChallengesParent faces two or more of the following challenges. Please tick the appropriate boxes. I am under 18 and have other challenges I started late antenatal care or did not make use of regular antenatal care I have or had a short interval between this pregnancy and my previous pregnancy/s I have or have had difficulties with depression, anxiety, mental health I have significant difficulties with drugs, alcohol, gambling My family/ whānau relationships can be problematic and stressful Oranga Tamariki have in the past been involved with my family/whānau or are currently involved My baby has needs: pre-maturity; low birth weight; special needs, health & development issues I have experienced abuse as a child My partner relationship is difficult at times – I do not feel supported, we argue a lot I have difficulties with housing, transport and or meeting the expenses of day to day living, e.g. electricity bills, rent, food and clothing. I and/or my family/whānau have been in trouble with the Police I struggled at school and left early I have moved at least twice in the last 12 months I want to improve my social skills: e.g. feeling good about myself, getting on with others, home management, budgeting, asking for what I need, learning to take care of myself and my family I do not have a lot of experience or confidence in parenting and want to learn to be a good parent I do not have many support networks I can rely on Please add any other relevant information: Other Agency InvolvementOther AgenciesIs your family/whānau engaged with or have they been referred to any other Agency? Yes No Tick which agencies you have been referred to: Waipuna Family Help Trust Te Puawaitanga Ki Ōtautahi Trust Other Other Agency DetailsPlease put name of Agency, contact person and date of referral if known. DogsDo you have any dogs on the property? Yes No Dog detailsPlease provide more information about the dogs on the property (size, breed, containment). Consent from parentParent Statement(Required) I give consent to have a referral for assessment forwarded to Early Start Project.Waiting List: Early Start Project operates a waiting list; the waiting times are variable and can range from as little as 4 weeks (or sooner) or stretch to 16 weeks or more. When a vacancy arises I understand that: Early Start Project will write to me and welcome me to the Service. A Family Support Worker/Whānau Āwhina will make contact with me by telephone or text to arrange a visit. The Service is free and my participation is voluntary. Parent's Name:(Required) Parent's Email(Required) Parent's Signature(Required)Draw your signature using either a mouse, digital pen or finger.
