Child & Young Person Referral

Child & Young Person Referral SEP2025

Contact

Referrer's Details
Child/Young Person's Details
Emergency Contact's Details & Current Living Arrangements
Therapy & Appointment Information
Other Information & Involved Services

Child or Young Person Therapy Referral

The following information is required to process your referral and may be used in a non-identifiable way by START for statistical purposes

Referrer's Details

Please complete the following details for the person making this referral.

Please complete all required * fields

Referrer: First Name

Last Name

Referrer's Phone/Mobile

Referrer's Email

Relationship to person being referred

Child or Young Person's Details

Please complete all required * fields

First Name

Middle Name

Last Name

Address:

Address Line 1

Address Line 2

Suburb

City

Postcode

Country

Date of birth

To quickly select your year of birth, click on the year (e.g. 2024) and type your year of birth

Gender

Man/Male

Woman/Female

Non-binary

Prefer not to say

Another term, let me type ...

Text Input

Preferred gender pronouns

He/him/his

She/her/hers

Ze/hir/hirs

They/them/their

Something else, let me type ...

Text Input

Ethnicity

Does the child/young person identify as Māori?

Yes

Iwi

Emergency Contact's Details & Current Living Arrangements

Please complete all required fields for the emergency contact person

Emergency Contact Person

Relationship to Child or Young Person

Is the emergency contact's address different from above?

Yes

Please Enter the Emergency Contact's Address:

Address Line 1

Address Line 2

Suburb

City

Postcode

Country

Emergency Contact's Phone Number

Emergency Contact's Email

Child or Young Person's Current Living Arrangements

Please give names and ages (where appropriate) of all other people who live at this address, including who they are in relation to the young person e.g. mother, sibling, boarder etc.

Is the mother named above?

Yes

Please enter mother's name

Please enter mother's address

Is the father named above?

Yes

Please enter father's name

Please enter father's address

Please describe the current care and/or contact arrangements

Therapy & Appointment Information

START expects parents/caregivers to be actively involved with the child or young person’s therapy wherever it is safe to do so

Please complete all relevant and required information

Who will the people be and what are their relationships to the child or young person?

Who is the best contact person in relation to appointments?

Please indicate days/times they could be unable to attend therapy

Please note that restricted availability for appointments may result in a longer waiting period

Any concerns that could impact weekly therapy attendance?

For example: transport, childcare, work etc.

Do you want to receive text reminders for the appointments?

Yes

Is it ok to leave telephone messages?

Yes

Is a Protection Order in place regarding yourself or your child?

Self

Child

No protection order

Who is the person named on the Protection Order?

Relationship of the person who harmed the child or young person

Is your child still in contact with this person?

Yes

Is there anyone else that you have safety concerns about for your child?

Yes

Other people of concern

Professional person or agency who the child or young person has disclosed to

Has an Evidential Interview been completed?

Yes

Has a Medical Examination been completed?

Yes

Has the information about the person who harmed the child or young person been reported to the Police?

Yes

Further details of Police involvement

Other Information

Please complete all fields as necessary

How did you hear about START's services?

Has the child or young person previously had an ACC Sensitive Claim?

Yes

Please include the ACC claim number: (if known)

Previous therapy provider

Doctor's name and Medical Centre / Practice contact details

What difficulties relating to the trauma is the child or young person currently experiencing?

Further important information to note for this child or young person

Other Involved Services

If any of the following services are involved (currently or previously) with the child or young person, please select below to allow START to contact them (where this is appropriate and applicable)

Child or Young Person’s name

1. Consent to obtain copy of Evidential Interview Summary

Note: disclosure needs to be evidenced for referral to proceed

Yes

2. Consent to contact GP (if appropriate)

Yes

3. Consent to contact STOP (if applicable)

Yes

4. Consent to contact other social services

Yes

Name of other social services

5. Consent to contact ACC regarding previous claim (if applicable)

Yes

6. Consent to contact Oranga Tamariki (where appropriate)

Yes

7. Consent to contact Mental Health Services (if applicable)

Yes

Mental Health Services involved

8. Consent to contact other agency regarding disclosure

Yes

Name of other agency

Consent

Please agree to START processing this referral by ticking the checkbox below and selecting today's date

I consent to START processing this referral and collecting any necessary information

Date