Future Youth Kaipātiki Referral FormBelow is our Referral Form for both Rangatahi, or whānau, to fill in if they want to enter the Future Youth Kaipātiki Programme. IntroductionWhat is involved in the programmeWhānau InformationWeeks 1 – 6Weeks 6+Partnering Information for BusinessesBusiness PartnersReferral FormRangatahi Details Your Name Your Email Date of Birth (DOB) Gender MaleFemale Ethnicity Mobile Address Main Contact Contact Name Contact Role ParentGuardianCaregiverOther Contact Email Contact Mobile Relationship to Rangatahi Is the Rangatahi and their Whaanau aware of this referral? YesNoReferrer Details Referrer Name Organisation Referrer Email Referrer Mobile Relationship to Rangatahi Referrer Address Barriers to employment ("tick" appropriate boxes) Anxiety/Mental HealthDrug and/or Alcohol UseFragmented Support NetworkDisengaged from education/supportsLack of self-esteem/confidence/resilienceYouth JusticeFinancial LiteracyCultural norms/expectations Referrer Expectations Other agencies/workers involved with Rangatahi DisclosureThe information provided in this form will enable Future Youth Kaipātiki Programmes to assess whether the referred rangatahi will meet the criteria of this Programme. Filling out this form gives no confirmation of enrolment in the Programme. In referring this rangatahi, you as the referrer agree to openly and transparently share information pertaining to the rangatahi and collaborate with the Future Youth Kaipātiki Programmes in ascertaining and promoting the best pathways forward for this rangatahi. This partnership approach of transparent communication will enable streamlined and tailored support for participating rangatahi and their whaanau. Referrer Acceptance Check here if you accept the above "Disclosure" Date For further information, please contact Lana, Future Youth Kaipātiki Team Lead Phone Email Location - 122/124 Anzac Street, Takapuna (Below Rock Shop)
