Referral Form - Franklin Family Support

Please fill in the form below if you would like to refer to us. If you would prefer to download and print out a copy please download the pdf version of this form by clicking on the pdf icon.

First Name *

Last Name *

DOB: *

Gender: *

Address: *

Home Phone: *

Mobile: *

Ethnicity: *

Iwi

Country Of Birth: *

Email Address:

Alternative Contact Name:

Phone:

IMMEDIATE SERVICES

Are you having thoughts about dying or feel at risk of self-harm or suicide

SOCIAL SERVICES

Family harm
Concerns and issues for individuals, whaanau / families
Oho workshop - small group work for women affected by harm, mental health and or addictions (4wks)
Aged 65 years and over and experiencing or at risk of abuse, harm or neglect

COUNSELLING (Unfortunately, our Counselling Service for Adults is at capacity. We apologise for the inconvenience. We will communicate with our community once we can accept new referrals.)

I would like to resolve issues and reach decisions. Work through loss, resolve and put to rest concerns, past trauma, anxiety, depression and anger. Add meaning to life.
My child/ren has/have witnessed violence (5-18yrs)

FINANCIAL MENTORING - If Applicable, please tick

Eviction
Disconnection
Debts
Re-possession
Rent
Future Planning
Ongoing Budgeting Support

PARENTING PROGRAMMES

Incredible Years 1 – 3 years for parents/caregivers with children 1 – 3 years
Incredible Years 3 – 8 years for parents/caregivers with children 3 – 8 years
Parenting Toolbox for teens - 6 week course for parents of teenagers 12 – 18 years

TRANSPORT

Transport to and from hospital appointments (48 hours notice is required)

Please provide any details that might help the team to further support you and/or your whaanau

REFERRER DETAILS: Have you (referrer) obtained consent from the client to make this referral *

YES
NO
Not Applicable

REFERRER NAME

REFERRER ORGANISATION

PHONE:

EMAIL:

Informed Consent: I understand this referral will go to the Franklin Family Support Services team so they can work together to provide the best support available. Confidentiality is maintained within the Franklin Family Support Service Team. *

YES

For comments, complaints or compliments please contact the Chief Executive Officer rdriver@familysupport.org.nz

How can you help?
– Donating
– Community Support

How can we help?
– Counselling Services
– Family Finance
– Social Services
– Transport
– Legal Services