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 or pregnant māmā) information

Client name (Child or pregnant māmā)

Client date of birth (Child or pregnant māmā)

Client address

Client phone number

Alternative phone number

Email

If child is under 19: Guardian's full name

If child is under 19: Relationship to child

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 (if you are self-referring, please enter NA)

Phone number (if you are self-referring, please enter NA)

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