Is the ākonga aware that you have referred your concern on? (Please inform student of the referral)
Clear selection
What support is required? *
Your answer
Strengths (e.g. social skills, sports or subjects) and protective factors (relationships with specific people, engagement in passions and interests) of ākonga:
Your answer
What has been attempted prior to this referral by kaiāwhina/kaiako/kaiārahi?
Your answer
Name of referrer (Your referral will be reviewed at our next Hauora hui on Tuesday and we will make contact following this)
Your answer
A copy of your responses will be emailed to the address you provided.