Circle of Security Parenting Referral Form

Parents may view their toddler or pre-schooler’s behaviour as challenging and find that current parenting responses are not effective.

Children must be aged 12 months and over, but less than 5 years to be eligible for referral.

Please fill out the referral form below, or for further information contact our PPAIRS team by email: ppairs.canterbury@plunket.org.nz.

I have obtained the client's consent to be referred and they are aware of what is in the referral form

The parent or caregiver has agreed to complete the 8-week course and can arrange childcare

I have informed the client that numbers are limited for each programme

Caregiver's name*

Caregiver's date of birth*

Caregiver's NHI *

Caregiver's ethnicity*

Address*

Phone*

Email address*

Partner's name

Child's name*

Child's date of birth*

Child's NHI*

Child's Ethnicity*

Details of other children (please provide name and age for each)

Is English a second language?*

Yes

Current situation for parent/caregiver

Are any of the following present? If so please check 'yes' and provide details in the box below.

Yes, one or more of the above conditions are present

No, none of the above conditions are present

Details of above*

Are any other agencies currently engaged with this family? If so, please provide details

Any significant parental physical or mental health concerns present?

Caregiver's ability to attend group*

Please list any known hazards for home visiting (e.g. dogs, history of violence)*

Name*

Relationship to client*

Role & Organisation*

Phone*

Email*