- KotahiConnect

West Coast Health - Youth Mental Health - Youth-Mental Health Referral Form (12yrs-24yrs)

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Self-Referral Referring yourself, or your whānau

Service Provider Referral Referring one of your clients.

Referrer Details

Provider Details

First Name

Last Name

Organisation Name

Contact Details

Phone Number

Email Address

Address

Physical Address

Address 1

Address 2

Suburb

City

Post Code

Postal Address is the same as Residential Address

Client Details

Personal Details

First Name

Middle Name(s)

Surname

DOB

NHI

Gender

Ethnicity1

add another

Contact Details

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Other Phone

Email Address

Address

Residential Address

Address 1

Address 2

Suburb

City

Post Code

Postal Address is the same as Residential Address

Referral Details

Youth-Mental Health Referral Form

Registered at a GP?

Name of Practice

Young person age group:

Young person is Under 16 and Parents and Guardian are aware of this referral. Young Person is over 16 and the Parents / Guardins do not need to be advised.

NOTE: If the young person is over 16 years old their parents / guardians do not need to be involved.
If the young person is under 16 years old, it is important that the parent or guardian is aware of the referral unless under exceptional circumstances this is not in the best interest of the young person.

Is the parent aware of the referral?

Are you happy for us to contact them?

Parent / Guardians Name

Parent / Guardians Phone

Referral Details

Reason for Referral

Please provide as much background information as possible, why you are referring into our mental health service, and what you would like to get out of the service, e.g goals for counselling. Please make sure you have included the main reason for request clearly.

Risk Assessment

Are you at risk to yourself:

Yes No

If yes, please provide details: ( if self-harming for example, please let us know here)

Are you having suicidal thoughts/Plan?:

Yes No

If Yes, Please use the box below to provide further information ( including any previous suicide attempts)

What would you like to get out of counselling? Any goals youwould like to achieve? Is there any other information that you think isimportant for us to know?