Youthline Central North Island Mentoring and Counselling Referral
Young Person's Details
First name
*
Last name
*
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender and pronouns
*
Ethnicity / iwi
*
Address
*
Street Address
Street Address Line 2
City
Phone number
*
Email
example@example.com
Name of parents/caregivers and contact details (if applicable)
*
Referral Type and Location
Type of referral
*
Mentoring
Counselling
Unsure
Preferred location
At education provider (school/kura etc)
Youthline CNI office
Which education provider?
Which Youthline CNI office
Palmerston North
Masterton
Referral Awareness and Contact Preferences
Does the young person know about this referral?
*
Yes
No
Do the parents or caregivers know about this referral?
*
Yes
No
Would the young person like to be contacted directly about this referral?
*
Yes
No
If no, who is the best person to contact?
Referral Details and Context
Reason for referral
*
Safety issues / level of risk regarding harm to the young person or others
Other agencies working with this young person or their family/whānau
Any other background information that would useful for us to know
What (if anything) has been discussed with the young person/whānau regarding the costs of counselling?
Does the young person have any preferences regarding the mentor/counsellor they meet with?
*
Outcomes hoped for from mentoring/counselling – young person
Outcomes hoped for from mentoring/counselling – whānau
Outcomes hoped for from mentoring/counselling – referrer
Referrer Details and Consent
Referrer name and agency
Referrer contact number
Referrer email address
example@example.com
Do you have the young person’s and/or parent/caregiver’s consent to make this referral?
*
Yes
No
I confirm that the information provided in this referral is accurate to the best of my knowledge
Yes
Submit Referral
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