Whetū Marewa Referral template

Real Whetū Marewa Tauranga Ph: 027 239 1561 Email: caleb.putt@real.org.nz BOP@real.org.nz

Taiohi/Youth Introduction Information Name:

Youth’s mobile:

Address:

Home telephone: Guardian’s name: Guardian’s mobile: Email:

NHI number:

Date of birth:

Gender:

Ethnicity:

Iwi:

Hapu:

Referrer:

School/Workplace:

Organisation:

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

Text

Email

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?

www.real.org.nz | www.facebook.com/realNZyouth Youth brand of Pathways | Part of the Wise Group.

Real Whetū Marewa Tauranga Ph: 027 239 1561 Email: caleb.putt@real.org.nz BOP@real.org.nz

Who does the young person live with?

Are their whanau/caregivers aware of referral?

Medical concerns / Allergies/ Relevant medication

Alcohol/drug concerns or involvement: Other Services that the Y/P has been involved with: Name:

Key contact and phone:

Name:

Key contact and phone:

Consent for above agency to be contacted for relevant information: YES / NO Persons Name & Signature ……………………………………………………

REAL Consent Form •

Real provides support with the things in life that you have identified and will build and maintain resilience confidence and wellbeing.

•

All information that is collected will relate to the service that we are providing.

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If you are under 16 we need your family/whanau or guardian to consent with you to receive support and to allow us to share information. If this is a challenge for you, then we can talk about how to get consent.

Signed: ________________________________ Date: _______________

Family/whanau or guardian name and signature Signed: _________________________________ Date: _______________ www.real.org.nz | www.facebook.com/realNZyouth Youth brand of Pathways | Part of the Wise Group.