IBA_Referral Form final

Referral Form Please complete the details below (pp. 1 -2) and EITHER email OR hand in a signed copy to the IBA staff Before completing the Referral Form, please consider the criteria checklist below.

Please note that in some circumstances, exceptions for accepting potential clients may be made, provided that the reasons for this are appropriately justified: Please note that if the person is being considered for s311, arson or sexual offending, or has a history of these offences, they will not be considered for the IBA or TBA programme. Does the person meet any of these criteria?

Yes

No

Any other criminal convictions or any charges pending?

Details:

Yes

No

Any known drug/alcohol related difficulties?

Details:

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Does the person meet any of the criteria below?

Any gang affiliations?

Details: Do you have any concerns around the person’s ability to communicate?

Details: Does the person have a disability and or any complex health needs (e.g. medication regime) that requires specialist intervention? These are assessed on a case-by-case basis.

Details: Does the person currently display any complex or acute mental health related needs, or active suicidal ideations that require specialist intervention? These matters are assessed on a case-by-case basis.

Details:

IBA, 3 The Strand, Tauranga, Bay of Plenty accounts@iba.org.nz 021 811 437 mark.mchugh@bopydt.org.nz 021952735 Page 1 of 3

Referral Form CLIENT NAME

DATE OF REFERRAL

NHI or CLIENT NUMBER DOB

AGE

ETHNICITY

DAY PHONE

MOBILE PHONE

CLIENT ADDRESS

LEGAL GUARDIAN (if applicable)

LEGAL GUARDIAN ADDRESS (if different)

LEGAL GUARDIAN PHONE (if applicable) CONTACT PERSON

REFERRING ORGANISATION CONTACT DETAILS

INDIVIDUAL HAS BEEN MADE AWARE & AGREED TO REFERRAL

REASON FOR REFERRAL

RELEVANT REFERRAL GOALS or EXPECTED OUTCOMES DETAILS OF OTHER PROFESSIONALS INVOLVED (GP's, Counsellors, Psychiatrists, Substance Abuse, Mental Health etc.)

SIGNIFICANT OTHERS INVOLVED CURRENT ACADEMIC STATUS - NCEA OR RELEVANT LEVELS LITERACY AND NUMERACY LEVELS ADDITIONAL INFORMATION

RELEVANT MEDICAL HISTORY

COMPLETED

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STARTED

Gender Orientation

Yes

No

Referral Form What is your highest educational achievement Have you ever experienced expulsions or stand downs from school, or been asked to leave school In the past 12 months, how many months have you NOT been in employment, education, or training Are you currently receiving any type of benefit (WINZ) support/MSD benefit Have you been on any benefit for six or more continuous months Do you have a driver’s licence Are you the primary caregiver for one or more children

PRIVACY AND PURPOSE

I, (NAME)_______________ _acknowledge that, in accordance with the Privacy Act 1993, any information on this form is both sensitive and personal and has been provided for the purposes of preparing the best possible approach to catering for the abovementioned applicant of the Imagine, Believe, Achieve (IBA) Programme. This information is collected for the purpose of assessing the potential applicant’s suitability for participation in the programme being conducted by IBA (on behalf of the Bay of Plenty Youth Development Trust), who could share this information with potential employers, training institutions or our government funders. The completion of this form does not mean that there is any obligation to accept the referred applicant on the programme.

SIGNED: _______________

_DATE: _______________

Thank-You for your referral If you would like to discuss any aspects of this referral further, please do not hesitate to contact us.

IBA, 3 The Strand, Tauranga, Bay of Plenty accounts@iba.org.nz 021 811 437 mark.mchugh@bopydt.org.nz 021952735 Page 3 of 3