External Agency Client Refferal Form

Fill out this form to refer someone to Sowers Trust.

Date of referral

Name of Client (First and Last)

Date of Birth

Age

Sex: Male / Female

Cell

Home Phone

Ethnicity

Iwi

Occupation

Name of Parent/Caregiver/Family (First and Last) (if appropriate)

Is the family aware of this referral? Yes / No

Comments (if appropriate)

Address

Home Phone of Parent/Caregiver

Email of Parent/Caregiver/Family

Cell of Parent/Caregiver/Family

Relation to Client

1. Details of Other Family Member

1. Date of Birth

1. Age

1. Gender

2. Details of Other Family Member

2. Date of Birth

2. Age

2. Gender

3. Details of Other Family Member

3. Date of Birth

3. Age

3. Gender

How did you hear about Sowers Trust?

Referral Details: Organisation

Address

Worker's Name

DDI of Referral

Fax of Referral

Cell of Referral

Email of Referral

Services Currently Supporting the Whanau: Please specify and give brief summary

What services may be helpful to you: Parenting, Social Work, Youth Mentoring, SowNGrow, Waves (bereaved by Suicide)

Is Oranga Tamariki involved with this whanau? Yes / No

Are you aware of any Police involvemet? Yes / No

Brief History and any expectations of the Sowers Trust

Please tick the box if it is ok to take photos/videos to be used for promotional reasons

Yes

I don't know

This consent form sets out the choices you have when you engage with Sowers.

Information Sharing

There are some new changes that came into effect from 1 July 2019 to section 66 of the Oranga Tamariki 1989 Act which include new provisions that give child welfare and protection agencies the ability to request, collect, use, and share personal information for purposes related to the wellbeing and safety of tamariki.

The information collected will only be shared for the reasons and purposes set out in the provisions. The information shared will be relevant to the wellbeing or safety of tamariki. We will talk with tamariki about sharing their information under section 66C unless it's not apprpriate or possible to do so. We will follow the Privacy Act 1993 requirements for handling personal information (like keeping information secure).

Privacy Statement for Collection of Personal Information

Sowers Trust is funded by Oranga Tamariki to provide support to young people and whanau.

I understand and agree that:

1. Information may be shared with the agencies that are also working with me.

2. I can decide to decline support from Sowers at any time.

3. Information about my whanau/family will be used for statistical purposes, but only information that does not identify any member of my family/whanau.

4. The Sowers Trust worker has explained the complaints process to me.

5. Agencies will only share my information with other agencies involved in this case. They will follow their agency's confidentiality code.

6. My family/whanau can choose to bring support people to meetings.

7. I can make suggestions about the meeting venue, cultural protocol to follow at the meeting, and any other needs I may have, such as translators, disability access, etc.

8. I understand how my whanau/family's personal information may be used.

9. I am entitled to a copy of this consent form.

If you would like to discuss a referral, arrange a visit or require any further information, please contact our referral coodinator on 09-538-0050 or referrals@hcc.co.nz.

I agree to Sowers terms and conditions.

I consent to transport myself or tamaraki under my care (if minor) in vehicle provided by Sowers if required (Yes / No)

I consent to obtain medical assistance if required (Yes / No)

Client Electronic Signature

Date

Thanks for submitting!