Admissions Form
To begin the admissions process, please use this form, providing as much information as possible. One form
can be used for multiple children from one family, and anyone can make a referral: parents, teachers,
doctors, social workers, or other family members. All information you submit will be kept secure and only
used for the purpose of admissions and planning for children's wellbeing during their stay.
Please send completed forms to:
email | melissa@cholmondeley.org.nz
fax | 03 329 9781
post | PO Box 12276, Beckenham, Christchurch 8242
Date Click here to enter a date.
Section One: Child/Family/Referrer Details
Child
Is this the child’s first admission to Cholmondeley? Select yes/no
First name: Enter first name
Date of birth: Enter DOB
Gender: Choose
School: Enter school name
Reason for admission: Enter text
Last name: Enter last name
Age: Enter age
Iwi/Aiga: Enter iwi/aiga name
Ethnicity: Choose
Admission type: Choose
Referrer
Referred by: Enter name
I am: Choose relationship
Phone: Enter phone
Mobile: Enter mobile
Family
Has the parent/caregiver given consent for this referral? Select yes/no
Number of children in family: Enter number
Age/s: Enter age/s
Mother’s contact details
Father’s contact details
Mother’s name: Enter name
Father’s name: Enter name
Street name & number: Enter street name & no.
Street name & number: Enter street name & no.
Suburb: Enter suburb
Suburb: Enter suburb
Postcode: Enter 4-digit postcode
Postcode: Enter 4-digit postcode
Phone: Enter phone
Phone: Enter phone
Mobile: Enter mobile
Mobile: Enter mobile
Emergency Contact
Name: Enter emergency contact name
Phone: Enter emergency phone
Usual caregiver of child: Choose
Address: Enter address if different from above
Phone: Enter phone if different from above
Section Two: Admissions Details
General information
Who will be transporting the child? Enter name
Are there any access/custody/court order issues? Select yes/no
If yes, please outline any special conditions/instructions/guidelines here
Tell us about the child at home: Enter text
Tell us about the child at school: Enter text
Has the child ever been suspended from school? Select yes/no
If yes, please give details here
Describe the strengths and interests of the child and the family: Enter text
Additional information: Enter any dietary needs, special comfort toys, nappies, bottles etc.
Has the child been involved in any fire-setting behaviour? Select yes/no
If yes, please give details here
Has the child displayed any sexualised behaviour? Select yes/no
If yes, please give details here
If yes to either of the above, has the child received any professional agency support with these behaviours? Select yes/no
If yes, please give details of the type of support received here
If yes, do you consent to Cholmondeley contacting the agency for further information relating to the child’s stay at Cholmondeley?
Select yes/no
Name of agency: Enter name
Contact person: Enter name and contact number
If yes, do you have any strategies (e.g. safety plans to support the child with these behaviours? Select yes/no
If yes, please give details where the child has a safety plan, they should bring this to Cholmondeley and a copy be made available to
staff
Has the child/family been affected by the Canterbury earthquakes? If yes, please explain
Other organisations involved with the child/family: Please list/describe
Medical
Health issues: e.g. allergies, asthma, epilepsy, wetting, soiling, sight, hearing
Current medication/s: Please list, including dosage and frequency
Has the child had their immunisations? Select yes/no
Doctor’s name: Enter name
Practice: Enter practice name
Phone: Enter phone
Payment
Does the child have Lifelinks respite funding? Select yes/no
Section Three: Consent
I give consent for Cholmondeley to share with and seek information from my child's school and other agencies which are working
with my family/whanau so that the best possible care can be given to the child.
Select yes/no
I give consent for my child to go off the property for supervised outings and adventure based learning (ABL) activities during their
stay at Cholmondeley. I am aware that this may include water-based, rope-based, rifles, archery, and camp fire activities.
Select yes/no
I heard about Cholmondeley’s services: Choose
Please now print the form, write your full name and signature in the spaces provided below, and send to Cholmondeley via one of the
methods specified at the top of this form.
Thank You
Full name parent/caregiver/delegated representative:
Signature:
Section Four: Office use only
Booking confirmed for:
Information pack sent:
Notes: