Hawkes Bay | Healthy Homes Initiative

Hawkes Bay - Child Healthy Housing Programme Referral Form

Refer to the Child Healthy Housing Programme below if you are in the Hawkes Bay rohe.

Client (Child) information

Child's name

Child's date of birth

Child's address

If child is under 19 fill out guardian information

Guardian's full name

Relationship to child

Phone number

Alternate phone number

Email

Please note the referral criteria are as follows: located within the greater Hawkes Bay area; whare with a child under 19 years of age (residing or regularly visiting); pregnant māmā; child with respiratory illnesses; individuals at risk of rheumatic fever or rheumatic heart disease (including recurrent GAS positive results); whānau receiving benefit.

Who is being referred into the Child Healthy Housing Programme?

Residency status

The parents/caregivers/family have a Community Service Card or are eligible for one

Referrer details

Referrer's name

Phone number

Email

Organisation

I would like to discuss this referral with Child Healthy Housing programme.

I would like to be informed of the outcome of this referral.

Informed consent: I/we give informed consent for the following -

I am happy to be referred to the Child Healthy Housing Programme to see if there are any services that will help improve my housing situation.

I consent to my data which could include photos being identified and used for research and evaluation of the Healthy Homes and Child Healthy Housing initiatives.

I am happy for the Child Healthy Housing programme and their contracted providers to share my information with any other agencies that can help improve my housing conditions.

I am happy for the Child Healthy Housing programme to access my child’s medical records if necessary, to check if they are eligible for services which may improve our health and housing conditions.

Address

Thank you for reaching out. Someone from Child Healthy Housing Programme will be in touch with you about this referral.

Supported by