Please provide as much information as you can. We will get in touch as soon as possible. Young Person's information First Name of Young Person: Last Name of Young Person Age of Young Person: Date of Birth: NHI number Gender Please Choose: Female Male Diverse Ethnicity Please choose: NZ Maori NZ European Cook Island Maori Pacific Island Other Young person's contact phone number Young person's email address: Young person's address For people under the age of 16, please include parent/caregiver details: Name and contact number What other services or people are currently/previously involved? This could include CYF, school counsellor, number 10 etc Referrer information (if different from above). If you are referring yourself please just put "self" in these boxes. Referrer name Referrer phone number Referrer email address: What is your agency/relationship to the young person? Other referrer contact details and when best to contact you: GP name: (If referring to Youth Brief Intervention Service in South Canterbury) What' going on? Why are you getting in touch with us? Please outline alcohol/drug or mental health concerns Safety Issues/Level of risk of harm to self or others: Background information: e.g. young person's family situation, accomodation, education, employment, relevant history Does the young person support the referral? Please Choose: yes no Do the parents/caregivers support the referral? Please Choose: yes no If under 16 we need the consent of a legal guardian to work with the young person.
