Please provide as much information as you can. We will get in touch as soon as possible.

Young Person's information

Name and contact number
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.

(If referring to Youth Brief Intervention Service in South Canterbury)

What' going on?

Please outline alcohol/drug or mental health concerns
e.g. young person's family situation, accomodation, education, employment, relevant history