Family Start Referral Form

Fill out the information below to apply or make a referral to the Family Start programme.

Who are you filling out this form for?

Parent's Information

First Name

Last Name

Mobile Number

Street Address

Parent/Caregiver's date of birth

dd/mm/yyyy

Ethnicity

Child's Information (2 years & under)

Please enter the information below for the child you are enrolling in Family Start.

Child's First Name

Enter "N/A" if the child hasn't been born yet

Child's Last Name

Child's Date of Birth

If child hasn't been born yet, please enter the expected due date

dd/mm/yyyy

Child's Ethnicity

Child's NHI number

Child's Street Address (if different from the parent/caregiver)

Age of other children in care

Please note: To be enrolled in this programme, parents must have at least one child under one year old, or be pregnant (for example, a mother with a six-month-old and a four-year-old would be eligible).

Family Start Criteria

Section A criteria

Please select all that apply:

Section B criteria

Anything else we should know?

The more we know about the situation, the more help we can provide.

Help@Hand Family Violence Prevention Watch

Do you have any current concerns around any serious Family Violence or the safety of any whanau members? If so, please apply for a safety watch below.

Would you like to apply for a Family Violence Prevention Watch?

Send me a copy of my responses

Report Abuse