YOUTH ENCOUNTER CLIENT REFERRAL FORM

  • YOUTH ENCOUNTER CLIENT REFERRAL FORM

  • This form is to be completed by the agency/person who is referring a client to Youth Encounter services. It is important to provide us with detailed information for us to assess if our services will be beneficial for the client. If we accept your referral this information will be confidential and enable us to work more effectively with the client for positive outcomes.

  • Engagement process:

  • 1. Make a referral (complete form below) - we will assess needs and suitability and contact you
    2. We will create a client plan for you to authorise and complete parent/caregiver consent
    3. We will then engage with young person to deliver client plan

  • Referral organisation/person

  • Referral organisation/person - Check all that apply*

  • Contact details

  •  -

  • Programme Services: Click here to see more at our website or go to www.youthencounter.co.nz/page/programmes/

  • Programme Service Fees - Notes: all fees below are at a subsidised rate

    • 1-1 Activity Therapy - 2hr weekly session for x8 sessions. Participant Fee: $3680 (incl. GST)
    • 1-1 Counselling - 1hr session with a counsellor (non-activity. Participant Fee: $90 (incl. GST) per session
    • Poutama Mentoring - 52 hours over 6-12 months of 1-1 Matched Mentoring. Participant Fee: $4830 (incl. GST)
    • Specialized Connect - 2hr activity session specialised to the participant needs. Participant Fee: $172.50 (incl. GST) per session

    What programme service/s you would like to access for the young person? Click here www.youthencounter.co.nz/page/programmes/

  • What programme service/s you would like to access for the young person?*

  • Transportation

  • Would you be able to provide transport for the young person if/when required?*

  • Client Details

  • Date of birth:*
     / /

  • Education

  • Health/medical

  • Referral Information

  • Referral reasons: Please select the reason(s) for the young person's referral to Youth Encounter
  • Tick any that apply;*

  • Primary referral reason: From your above selections, please select the PRIMARY (most important) reason for the young person's referral to Youth Encounter

  • Mark the most applicable one;*
  • Agencies Involved: Are there any government agencies involved with the young person? Check all that apply;*

  • Client Information

  • Risk Factors:

  • From what you know of the young person and wish to disclose, please indicate any of the following risk factors you are aware of. This helps us to provide the most appropriate support. Risk factors are experiences or conditions that increase the likelihood of behaviours or challenges that can impact a young person's physical, social, emotional, and spiritual well-being.

  • Risk Factors

  • Protective Factors:

  • From what you know of the young person and wish to disclose, please indicate any of the following protective factors you are aware of. This helps us to provide the most appropriate support. Protective factors are strengths, supports, and positive influences that help young people cope, build resilience, and thrive despite challenges.

  • Protective Factors
  • Disclosure: I hereby certify that the above information is true and correct to the best of my knowledge.*
  • Should be Empty: