Dragonflies Referral Form

The Dragonflies Tamariki Programme is a 10-week safety programme for children between the ages of 5 to 12 years, who have witnessed or experienced family harm. The aim for the facilitators, from Palmerston North Women’s Refuge, is to provide education within an encouraging environment where children are able to talk openly about their feelings in relation to family harm, share their experiences of family harm and know that they are supported. Please note, Dragonflies is not acounselling or therapy service.

Where the youth is under the age of 16 a parent or caregiver MUST consent to this referral.

Information

Referral Date:

Name of Individual Referring:

Name of Agency / Organization Referring:

Address:

Phone

Parental Consent Received? (Required if under 16)

YES

Parent / Caregiver Details

Name

First

Last

Date of Birth:

Address:

Phone

Gender:

Protection Order?

YES

Food Allergies:

Family court where the protection order was granted:

Name of the respondent to the protection order:

Ethnicity:

Iwi (if applicable):

Wise Programme?

YES

Child 1 Details

Name

First

Last

Date of Birth:

Gender:

School:

Food Allergies:

Child 2 Details

Name

First

Last

Date of Birth:

Gender:

School:

Food Allergies:

Child 3 Details:

Name

First

Last

Date of Birth:

School:

Gender:

Food Allergies:

Emergency Contact:

Name

First

Last

Phone

Further Information (include history of family harm and main concerns for the youth):

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