Referral – Rubicon Youth

Young person's details

Name

First Last

NHI

DOB

Age

Ethnicity

Gender

Address

Street Address Address Line 2 City Suburb Post Code Country

Phone

Mobile

Email

School

Year

GP

Consent for referral: young person

Yes
No

Guardian details

Guardian

First Last

Relationship

Address

Street Address Address Line 2 City Suburb Post Code Country

Phone

Mobile

Email

Alternative contact

First Last

Relationship

Address

Street Address Address Line 2 City Suburb Post Code Country

Phone

Mobile

Email

Consent for referral: parent/guardian

Yes
No

Whanau details

Mother

Name

First Last

Phone

Mobile

Email

Father

Name

First Last

Phone

Mobile

Email

Referrer details

Name

First Last

Agency

Role

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone

Mobile

Email

Other Agencies

Agency 1

Caseworker

First Last

Agency 2

Caseworker

First Last

Agency 3

Caseworker

First Last

Agency 4

Caseworker

First Last

Other

Caseworker

First Last

Level of risk

Are there any environmental risks for staff? eg dogs, long driveways etc

Yes
No

What are the environmental risks for staff?

Is this young person at immediate risk, eg self-harm, suicidality?

Yes
No

If yes please provide risk assessment, safety plan and list of other agencies involved.

Reason for referral and background information

Please list substance of concern and any other problematic areas, eg violence, bullying, anxiety, grief and loss, physical health.

Entry Criteria

12-19 years age group (some flexibility is acceptable)
Residing within the Northland DHB region boundaries
Bio-pyscho-social health issues
Mental health issue/s
Alcohol and other drug use issue/s

Service entry will be managed promptly. There is no waiting list. Prioritisation considers safety and risk issues.

CAPTCHA

Referral Form

Young person's details

Guardian details

Alternative contact

Whanau details

Mother

Father

Referrer details

Other Agencies

Level of risk

Reason for referral and background information

Entry Criteria

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