PPNAP Referral Form - Canterbury » Whānau Āwhina Plunket

Please note this form is only to be used for Canterbury-based clients. Please use the separate forms for South Canterbury or Dunedin-based clients.

Referrer's responsibility

I have obtained the client's consent to be referred

The child is under 1 year of age (or under 2 years if Tangata Whenua)

My client is aware if they do not confirm their appointment 48 hours in advance, it may be cancelled and they will be placed back on the waiting list

Note: Referrals are allocated once a fortnight. Clients will be notified by email within 14 working days from receipt of referral.

Mother's details

Mother's name*

Mother's date of birth*

Mother's NHI *

Ethnicity*

Address*

Phone*

Email address*

Details of baby and other children

Expected due date (if this is an antenatal referral)

Baby's date of birth (if already born)

Baby's name

Baby's NHI

Baby's gender

Baby's Ethnicity

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

Partner's details

Partner's name

Partner's ethnicity

Details of other household members (if any)

Referral/assessment details

Reason for referral (please provide as much information as possible)*

Current situation for parent/caregiver

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

Mothers and Babies service/Adult mental Health (if the client is involved with another specialist mental health service, the referral will be declined)
Other agencies referred to/already involved
Concerned about relationship with baby
Grief/loss
Unexpected outcome of pregnancy, labour or delivery
Medical issues
Plunket Parent and Infant Relationship Service
Current Anxiety/Mood change
Past psychiatric history
External stressors
Trauma
Oranga Tamariki involvement

Yes, one or more of the above conditions are present

No, none of the above conditions are present

Details of above*

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

EPDS score (out of 30)

Date of EPDS score

Referrer's Details

Name*

Role & Organisation*