Real Whetū Marewa Tauranga Ph: 027 578 7063 Email: danica.thompson@real.org.nz BOP@real.org.nz
Taiohi/Youth Introduction Information Name:
Youth’s mobile:
Address:
Home telephone: Guardian’s mobile: Email:
NHI number:
Date of birth:
Gender:
Ethnicity:
Iwi:
Hapu:
Referrer:
School/Workplace:
Referrer Contact Details: Date of Referral: Doctor or GP name: Is the young person aware of the referral? Y/P’s level of motivation 1-10: Y/P gives consent for Real to contact by:
Phone
Risk to Self or others (If yes- explain)? What are the primary issues for the young person? How long has it been a difficulty? When is it better/worse? How is it impacting the young person’s life? What are the goals/ What are you/they hoping for from Real? Who does the young person live with?
www.real.org.nz | www.facebook.com/realNZyouth Youth brand of Pathways | Part of the Wise Group.
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