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CLIENT REFERRAL FORM
This form is to be completed by the agency/person who is referring a client to Youth Encounter services. It is important to provide us with detailed information for us to assess if our services will be beneficial for the client. If we accept your referral this information will be confidential and enable us to work more effectively with the client for positive outcomes.
Engagement process:
Make a
referral
(complete form below) - we will assess needs and suitability and contact you
We will create a client
plan
for you to
authorise
and complete parent/caregiver consent
We will then
engage
with young person to deliver client plan
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* Indicates required question
Referral organisation/person
*
Youth Justice
Oranga Tamariki
Police
Community Service Provider
School
Alternative Education
Parent / Caregiver
Other:
Required
Referral organisation details
Please provide address and contact phone number of the referral organisation if applicable
Your answer
Your name
*
Your answer
Your email
*
Your answer
You phone number
*
Your answer
Your relationship with the client
*
Counselor
Mentor
Parent
Primary Caregiver
Social Worker
Teacher / Tutor
Youth Aid Officer
Other:
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