Steps to Success Referral Form

Rangatahi Details

Address

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Main Contact

Relationship to Rangatahi Is the Rangatahi and their Whaanau aware of this referral? YesNo

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Referrer Details

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

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Rangatahi Overview

Expand on presenting barriers to employment Other relevant information Highest Qualification Achieved No QualificationNCEA Level 1NCEA Level 2NCEA Level 3NCEA Level 4-6NCEA Level 7 or above Has the Rangatahi ever experienced expulsion/s, stand down/s from school, or been asked to leave? YesNo Is the Rangatahi currently in some form of employment, education, or training? YesNo In the past 12 months, how many months has the Rangatahi NOT been in education, employment, or training? 0 months1 month2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months12+ months Is the Rangatahi currently receiving any type of WINZ support/MSD benefit? YesNo What Drivers Licence does the Rangatahi hold? No LicenceLearnersRestrictedFull Does the Rangatahi have any dependants? YesNo Does the Rangatahi have any criminal convictions? YesNo Has the Rangatahi been involved with Police previously? YesNo How old was the Rangatahi when they last attended school? Did the Rangatahi become unemployed, or leave school or training because of COVID-19? YesNo

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Disclosure

The information provided in this form will enable Steps to Success 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 Steps to Success 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.