Takiri Mai Te Ata Trust > Referral Form

First name

Whānau name

Date of birth

Age

Ethnicity

Gender

male female

IWI

NHI#

Number of tamariki/mokopuna

Age range

0-4 years
5-10 years
11-17 years

Address

Home phone

Work phone

Mobile phone

Email

Preferred contact number

Current medical centre

Referral date:

Referrer name

Organisation

Referrer Contact Details

Fax number

Has whānau been informed?

yes no

COLLECTIVE SERVICES

Naku Enei Tamariki (Maori Section) (NET)

Tamariki Details If Applicable

Pēpē Due Date

Required for Te Awhi o Te Rito Hapū Wānanga

Or Pēpē Name

LMC/Midwife Name

Required for Te Awhi o Te Rito Hapū Wānanga

Baby's date of birth

Baby's NHI#

Services required

Early Intervention - Nurture,Enjoy,Teach 0 - 5 Years
Family Start for vulnerable whānau 0 - 12 months
Incredible Years Parenting Program 3 - 8 Years
Maioha te mana Mouri 0 - 5 Years
Te Awhi o te Rito Hapū Wānanga
Awhi Mai Awhi Atu

Tu Kotahi Maori Asthma Trust

Services required

Asthma
COPD
Bronchiolitis
Well Homes
Other Respiratory

Mana Wahine

Services required

Cervical Screening
Breast Screening
Te Mauri- Whakamana Māori Whānau with Cancer

Kokiri Marae Keriana Olsen Trust

- Whānau Ora Social Services
- Tihei Rangatahi - Programmes for Wainuiomata Rangatahi
- Kāti te Tūkino - Supporting Violence Free Whānau
- Tama Tū Tama Ora - Mens Non Violence Group
- Te Ao Marama - Wahine Anger Management Group
- Kaumatua Support Services
- Whanau Ora Hapū Māmā
- Sexual Health Clinics
- Outreach Diabetes Service
- Outreach Immunisation Service
- Child Car Seat Rental Scheme
- Hā Whakatā

Moe Ora Mo Ngā Pēpē

Wahakura/Pēpē Pod Criteria

Smoke Exposed to baby
Safety concerns identified by clinician
Māori/Pacific people prioritised

Kokiri Marae Maori Women's Refuge

Servies required

Whakaoho Wairua Living without Violence Programme
24 Hour Crisis Line - 04 566 5025
Safe House Support

Tākiri Mai te Ata Services

Services required

Whānau Ora Navigator Services
Regional Stop Smoking Services
Homelessness Prevention (Early Intervention Service)
Budgeting
Mental Health
Te Kete Aronui - Therapeutic Music Prog for Rangatahi

Whai Oranga O Te Iwi Health Centre

Services required

Comprehensive Primary Health Services
Community Dental Service for Adults
& FREE Adolescent Dental Services for aged 13 - 18 years.

Wainuiomata Marae - Ph: 5648395

Services required

WOA Social Service Support
A wonderful venue and facilities
Ora Tika- Rongoa Maori

Reason for Referral

Reason

How soon is intervention required?

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