Enquiry - 18 | Wellington Sexual Harm Help

Your Details

Your full name

Your phone number

Your email address

How do you know the person you are referring?

Your agency

Preferred way to contact you

Phone Text Email No preference

Best time to contact you

Has this person given consent for this referral?

Yes No

Has a notification of concern been made to OT?

Yes No

Their Contact Details

Their full name

Preferred name

Their phone number

Their email

Address

Preferred way to contact them

Phone Text Email No preference

Best time to contact

Is this urgent?

Yes No

Who should the first point of contact be?

Parent / Guardian Person being referred

About Them

Where are they located?

Their date of birth

Their gender

Please specify other ethnicity

Their pronouns

She/her He/him They/them Other (please specify)

Please specify other pronouns

lwi

Parent / Guardian

Name of parent/guardian

Phone number

Email address

Address

Preferred way to contact

Phone Text Email No preference

Best time to contact

Please specify other ethnicity

Iwi

Referral Background

Time Frame

Acute Recent Historic

Please provide brief detail (if known)

Please provide full details agency, worker and nature of historic involvement

Risk Profile

Are you aware of any of the following (current / recent)?

Please provide details

Current safety concerns - please detail all known current risks to safety and welfare

Current safety plan - details of current safety plan, including details of people / agencies involved

Current mental health status - please include medication details, if known

Details of abuse and disclosures - what is known about the nature of abuse, when it happened, where it happened, who did it, was the abuse disclosed, who to, when, etc.

Support Needs

Have they accessed HELP services before?

Yes No Not sure

Is there anything else you want us to know?

Under 18 referral form

Enquiry form for minor

Thank you for your referral!

Your Details

Their Contact Details

About Them

Parent / Guardian

Referral Background

Risk Profile

Support Needs