| 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? |
|
|
|
|
