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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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.