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| Sowing Seeds of Hope |
He iti hau marangai, e tū te pāhokahoka
sowers@hcc.co.nz
(09) 538-0050
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Meet the team: Ameet
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Meet the team: Belinda
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Referral Form
Referral Form
Client Information
Name of Client*
Date of Birth*
Gender
Male
Female
Other
Client’s Address*
Parent/Caregiver/Family Information
Is the family aware of this referral?
Yes
No
Details of family members.
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How did you hear about Sowers Trust?
Police
Oranga Tamariki
School
Google
Doctor
Other
Referrer Details
Referrer’s Name*
Referrer’s Address*
People who currently provide support
Family
Community Organisations
Friend/Neighbours
Professional Support/Organistaion
Other
Please highlight services that may be helpful to you
Parenting
Social work
Youth Mentoring
Sow and Grow
Strengthening Families
Waves (bereaved by Suicide)
Please specify and give a brief summary*
Brief History and any Expectations of the Sowers Trust.
I agree to work with a Community Worker of The Sowers Trust and that this includes children under the age of 18 if working with the whole family. I understand that the information given will remain strictly confidential, unless I give permission verbally or in writing for any of my details to be released. I understand that the Community Worker will break confidentiality if there are any concerns for safety of self or others.
Signature*
For use at Sowers Trust or if you are printing this form.
Photos and/or videos*
During sessions/groups we run there may be photos or videos taken for promotional reasons. Do you agree to photos/videos being published on our website/facebook page?
Yes
No
Yes – No facial recognition
Submit
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