Mirror HQ Youth Referral Form

Name *

Date of Birth *

NHI (if known)

Address and Postcode

Phone *

Email Address

Ethnicity

Iwi

Name

Address and Postcode

Phone

Email

Name of Worker

Referral Agency

Address and Postcode

Phone

Email Address *

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

What is the purpose of this referral?

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

Alcohol and other drugs/behavioural addictions:

Physical/mental/emotional health - current/past diagnosis:

General comments:

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

Has this young person been informed, and do they consent to attending our service?

Yes

No

Does the young person consent to Mirror HQ Youth Addiction Service liasing with other services in regards to this referral?

Yes

No