Report of Concern to Child, Youth and Family Call us on: 0508 326 459 (0508 FAMILY) Email address for sending the written referral: cyfcallcentre@cyf.govt.nz or Fax: (09) 914 1211 (telephone and e-mail is our preferred method) Before you make this referral we encourage you to speak to whānau about your concerns and let them know your plan to contact Child, Youth and Family. However if children (or you) are at immediate risk of harm, we understand you may make a referral without contacting the child’s whānau. If you have spoken with a Child, Youth and Family social worker about this referral, please record Name of Social Worker: Date/time of conversation: Outcome of the discussion: Wherever possible we will work with you and will endeavour to make contact with you prior to visiting the whānau. We prefer you speak to a social worker at our National Contact Centre by phone 0508 326 459 (0508 FAMILY), so you can discuss your concerns and answer any questions the social worker may have to help inform their decision about the next step. Where your agency requires a written referral please send a copy of this document (we prefer an electronic word document). This form may ask for information you do not have, that’s okay. For these please write “not known/not applicable”. The more information you can share, the better our decision making will be and the better the outcome for the child will be. Your details Date: Your name and role: Your email address: Your contact phone number/s: Your afterhours contact phone number: (for emergency situations only) Your organisation: Your postal address: Alternate contact person: Alternate contact person phone number/s: Please advise if you wish your identity to remain confidential. We generally do not disclose your identity but there may be exceptional situations where we may have to. Should this occur we will let you know. Keep in mind that families may form their own views on who made contact with Child, Youth and Family. Have you informed the whānau that your concern is being reported to Child, Youth and Family? What steps have you taken to discuss and address your concerns with the whānau or through referrals to other agencies before referring to Child, Youth and Family? What was their response? Key Information: Please enter information below for all the children and young people in the whānau that you are concerned about including their siblings Child’s Name: Also known as: Date of Birth: (or Expected Due Date) Unique identifier (e.g. NHI, NSN): Gender: Child’s address: (This is essential information to enable the CYF contact centre to refer the case to the appropriate CYF site) Ethnicity: (include Iwi/Pacific Island Affiliation if known) Child’s Name: Also known as: Date of Birth: (or Expected Due Date) Unique identifier (e.g. NHI, NSN): Gender: Child’s address: (This is essential information to enable the CYF contact centre to refer the case to the appropriate CYF site) Ethnicity: (include Iwi/Pacific Island Affiliation if known) Please add any additional children and their details below: Mother’s name: Also known as: Date of Birth: (or approximate age) Phone number: Address: Father’s name: Also known as: Date of Birth: (or approximate age) Phone number: Address: Who else is living in the home (name and age): If a child has a parent/carer different from those stated above please provide the details and their relationship to the child/ren: Other whānau or people involved in the care of the child/young person: (please include, name, relationship to the child, address and contact phone number) Early Childhood Education / School: (please include, contact person and contact phone number) It is helpful to know who else is working with the whānau. We may need to talk to the agency before talking with the whānau. Please tell us about other agencies working with this whānau. Agency Contact name Contact number Why/how are they involved General Practitioner Alcohol/Drug and Other addiction services Child and Adolescent Mental Health Service Community Mental Health or Addiction Services (adult services) Cultural Support DHB Social Worker Disability Services Family Start Maternity Service/Lead Maternity Carer If antenatal referral, what is the expected date of delivery? Plunket / Well Child / Tamariki Ora Police Public Health Nurse Special Education / School Counsellor / SWISS/MASSIS Children’s Team Other e.g. Paediatrician, NGO social service (please specify) What was the outcome of your discussion with them about referring to Child, Youth and Family? (It is helpful to know why they are involved and what they are working on with the whānau) Reason for referral Please describe what your worries and concerns are for this child or young person, this group of children and their whānau: What is your main concern for this child or young person? Describe what you are observing, what you have heard or what you have been told rather than using general terms such as “emotional abuse” Note in the child or young person’s words anything they may have said to concern you (When did they say it and to whom?) Make note of how recent and frequent any specific incidents or events are (explain who, what, when, how?) Describe any other issues that could be impacting on the child or young person e.g. family violence, chronic ill health, disabilities, mental illness, substance misuse, lack of support, truancy, behavioural, family stress, transience, criminal history, non-engagement/avoidance of services and describe how this has affected the child or young person? Source of the information (e.g. observed directly or name and contact details): What has prompted you to refer to Child, Youth and Family now? (What are your immediate safety concerns for this child or young person?) Where is the child or young person now? (e.g. school, hospital, home) Who in the whānau or friends of this whānau can help provide support around the concerns you have and how can they do this? (Please provide contact details) What is working well for this whānau? (What needs of the children and young people are being met and how does this happen?) What is in place to support the whānau and keep the children or young person safe currently? (Services and agencies providing support, family and friends visiting, people providing care for the children) Tell us why you think Child, Youth and Family is the most appropriate agency to assess the needs and circumstances of this whānau now? (What have you already tried to address the concerns? What is currently in place to address your concerns? What would you like Child, Youth and Family to do?) What other needs have you identified for this whānau? (Disability, language, cultural) What happens next? A social worker at our National Contact Centre will read your report of concern and make a decision as to the next best step to ensure the safety of the children or young people in this whānau. They may need to talk to you to clarify some information to help them make the best decision for these children or young people. Please ensure you are available to be phoned by the social worker. Developed in collaboration with New Zealand Police, Ministry of Health and Ministry of Education Version 1 December 2014 Use the buttons below to send this completed form to Oranga Tamariki / CYFS Please note you need to have access to email to complete this function