If you or someone you know is in immediate danger, call 111. After hours: 0800 733 843

Family violence support

Social work support referral

Refer yourself, a family member or someone you work with for social work support. Complete the form online, or download the Word version and email it back.

Before you start

Referral for social work support

Please complete this form to refer yourself or someone else for social work support. We will be in touch within three working days. Fields marked * are required.

Please only refer someone with their knowledge and agreement. If you are referring someone else, they need to know about the referral and agree to it.

This is not an emergency service. If you or someone else is in immediate danger, call 111. For urgent mental health support, call or text 1737.

1 Referral details

Who is making this referral? *

Self-referral Professional / agency Family / whānau member Other

Date of referral *

2 Referrer details

Complete this section if you are referring someone else.

Your name

Organisation (if applicable)

Role / job title

Relationship to the person

Phone

Would you like an update on this referral?

Only shared with the person’s consent.

Yes No

3 Person being referred

Full name *

Preferred name

Date of birth / age *

Gender

Ethnicity

Iwi / hapū or Pacific nation(s) (optional)

First language

Interpreter needed?

Yes No

Language

Address

Phone

5 Household and whānau

People living in the home, including children. Leave blank if not known or not applicable.

Name	Age	Relationship to person	Lives in home?

On a phone, scroll sideways to see all columns.

8 Other services involved

Leave blank if not known or not applicable.

Service / agency	Contact person	Phone / email

On a phone, scroll sideways to see all columns.

10 Consent and privacy

Weave Family Solutions collects this information to assess the referral and provide support. It is stored securely, is only seen by staff involved in the person’s support, and is managed in line with the Privacy Act 2020. The person can ask to see or correct their information at any time.

Information is kept confidential, except where there is a serious risk to someone’s safety.

11 Declaration

Name *

Signature (type your full name)

Date *

I confirm the information in this form is accurate to the best of my knowledge. *

Your details are sent securely and stored for this referral. Read the privacy policy.

Prefer paper?

Download the Word form

Complete it offline and email it to info@weavefamilysolutions.com. The online form asks for the same information.

Download the form

Word document · 25 KB

What happens next

We receive the referral. It goes to the social work team, not a shared inbox.
We review it within three working days. If anything is unclear, we will contact the person or referrer using the safe details provided.
We arrange the first kōrero. We check the fit, the support needed and how to work together safely.

Confidentiality

Referral information is stored securely, seen only by staff involved in the person’s support, and managed under the Privacy Act 2020. Information is kept confidential, except where there is a serious risk to someone’s safety.

Read the privacy policy

Not an emergency service

If you or someone else is in immediate danger, call 111. For urgent mental health support, call or text 1737.

Email Book a kōrero