Mirror HQ Youth Addiction Service Referral Form

Name: *

Gender: *

Date Of Birth: *

NHI:

Address and Postcode:

Phone: *

Mobile:

Ethnicity:

Iwi:

Current School:

Other Schools Attended:

Mother's Details

Name:

Address and Postcode:

Phone:

Work Phone:

Mobile:

Other people living at this Address:

Father's Details

Father's Name:

Father's Address and Postcode:

Phone:

Work Phone:

Mobile:

Other people living at this Address:

Caregiver's Details

Name:

Address and Postcode:

Phone:

Work Phone:

Mobile:

Other people living at this Address:

Referrer's Details

Referrer:

Referral Agency:

Address and Postcode:

Email Address:

Name of Worker:

Phone:

Preferred Counsellor:

Are there any other agencies previously or currently involved with this family?:

What does the child, young person/whanau hope to gain from counselling?:

Have there been any significant events in the life of this child/young person? (Parents separation/traumatic events/grief and loss, familial alcohol and other drug use etc.):

Are there any immediate risk factors for this child/young person or others?:

Alcohol and Other Drugs/Behavioural Addictions:

Please note any concerns in the following areas:

Physical/Mental/Emotional health. Current/Past diagnosis:

School/course/employment:

Relationships:

Other:

General comments:

We do not accept referrals for young people who haven’t been informed of being referred to our Service.

Mirror HQ Youth Addiction Service Referral Form

Aroha Ki Te Tamariki Love for the Children