PPNAP Referral Form - Dunedin » Whānau Āwhina Plunket

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

Referrer's responsibility

I have obtained the client's consent to be referred

I confirm the child is under 12 months of age

I have informed the client of the potential wait of 6+ weeks for an appointment

Note: Clients will be notified within 7 working days after 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.

Involvement with Health NZ | Te Whatu Ora
Concerned about relationship with baby
Grief/loss
Unexpected outcome of pregnancy, labour or delivery
Medical issues
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*

Phone*

Email*

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