Mirror HQ Youth Referral Form

Details of Young Person

Date of Referral *

Name *

Gender *

Date of Birth *

NHI number (if known)

Address *

Post Code

Cell *

Email *

Ethnicity

Iwi

Current School or Employment

Parents or Caregivers Details

Name

Address

Post Code

Cell

Email of Parent/ Caregiver (1)

Relationship to Young Person

Other People Living at this Address

Name

Address

Post Code

Cell

Email of Parent/Caregiver (2)

Relationship to the Young Person

Other People Living at this Address

Any further comments or details

Referrer Details

Referral Agency

Postal Address

Post Code

Email of Referrer *

Name of Worker

Referral Questions

Are there any agencies previously or currently involved with this young person and whānau?

What support is this young person seeking?

Are there any relevant health factors you would like us to know about, including mental, social, whanau, spiritual or physical factors:

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

What are the young person's strengths and protective factors?

Are there any cultural considerations we should be aware of?

Other

Does the young person have any preferences for their counsellor/clinician/peer support?

Is there any other relevant information you would like us to know about?

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

Does the Young Person consent to Mirror HQ liaising with other services as part of the intake process?

Yes

No

Mirror HQ Youth Referral Form

Mirror HQ Referral Form 2025

Details of Young Person

Parents or Caregivers Details

Referrer Details

Referral Questions