EaseUp Referral Form
Please select from the following options:
*
I'm a young person seeking help/support
I'm supporting a young person to seek help
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Self-Referral: "I'm a young person seeking help"
Please fill out the below.
Legal First Name
*
Legal Last Name
*
Preferred Name
*
Pronouns
e.g. she/her he/him they/them
Date of Birth
*
-
Day
-
Month
Year
Note: If you're under 16, we'll need consent from a parent or guardian!
Mobile Number
*
-
Email Address
*
example@example.com
School you're currently enrolled at OR work (if any)
NHI number (if you know it)
Gender
Ethnicity
Iwi (if applicable)
Address:
*
Address (only for our records) - we only support those based in central, North, West Auckland and South Waikato.
*
Street Address
Suburb
City
Post Code
Emergency Contact Name
*
Emergency Contact Phone Number
*
-
Their relationship to you
*
Do you have concerns about your own safety?
*
Yes
No
Which EaseUp area do you live in?
*
Auckland Central
West Auckland
North Shore/Rodney
South Waikato
What would you like support with?
*
Alcohol
Vaping
Other Drugs
Anxiety
Bullying
Low Mood
Relationship issues
Identity
LGBTQI+
Self-harm
Gaming addiction
Healthy lifestyle
Grief
Gambling
Goal-setting
Other
Please tell us a little bit about what you've chosen from the above list:
What's the best way for us to contact you?
Email
Phone Call
Txt message
What's the best way for us to contact you?
Email
Phone Call
Text Message
How would you prefer to access this service?
In Person
Online
How did you hear about EaseUp?
Word-of-mouth / someone you know
Facebook or Instagram
TikTok
Google
School
GP
Other
How did you hear about EaseUp?
Please Select
Someone you know
School
TikTok
Facebook or Instagram
Google
GP
Other
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Referring someone else: "I'm supporting a young person to seek help"
Please fill out the below.
Is the young person aware of AND consenting to this referral being submitted?
*
Yes
No
Your Name
*
Your Email Address
*
Your Phone Number
*
Your relationship to the young person
*
Young Person's Full Name
*
Young Person's Preferred Name
Young Person's Date of Birth
*
-
Day
-
Month
Year
Note: If they're younger than 16, parental consent is required.
Has parental consent been gained?
*
Yes
No
If parental consent HASN'T been gained, please explain below:
Not having consent for an under 16 requires a discussion around rationale with us. Please contact us directly to discuss, if this is the case.
Gender
Pronouns
e.g. she/her he/him they/them
NHI number (if known)
Young person's current school or work
Young person's Ethnicity
Young person's Iwi (if applicable)
Young Person's Mobile Number
*
-
Young Person's Email Address
*
example@example.com
Address:
*
Young Person's Address (for our records only) - we only support those based in central, North, West Auckland and South Waikato
*
Street Address
Suburb
City
Post Code
Emergency Contact Name
*
Emergency Contact Phone Number
*
-
Their relationship to the young person
*
Which EaseUp area do they live in?
*
Auckland Central
West Auckland
North Shore/Rodney
South Waikato
When is the best time to contact them?
Anytime
After school
After work
Weekend
Are they currently getting help/support/counselling from any other source for mental health or addictions? If yes, please provide details.
Presenting issues:
*
Alcohol
Vaping
Other Drugs
Anxiety
Bullying
Low Mood
Relationship issues
Identity
LGBTQI+
Self-harm
Gaming addiction
Healthy lifestyle
Grief
Gambling
Goal-setting
Other
Please tell us a little bit about what you've chosen from the above list:
*
What would you like the young person to achieve from engaging with EaseUp?
Would you like EaseUp to contact you (the referrer) or the young person?
*
EaseUp to contact referrer
EaseUp to contact young person
Please tick all that apply below - are you concerned about the young person's risk...
*
To themselves
To others
From others
No current concerns
If you selected any of the above concerns, please outline any safety planning that has taken place:
How did you hear about EaseUp?
Word of mouth / someone you know
Facebook or Instagram
TikTok
Google
School
GP
Other
How did you hear about EaseUp?
Please Select
Someone you know
School
TikTok
Facebook or Instagram
Google
GP
Other
Back
Submit
Next
Nearly there! Press the 'submit' button below.
Click here to submit
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