Referral - Cromwell Youth Trust

Please fill in this referral form with as much detail as possible.

It is important we get a clear understanding of the need for mentoring.

Please Note: Filling in this referral form DOES NOT guarantee acceptance to our mentoring programme.

Each referral is evaluated to see if the young persons needs are suitable to what CYT Youth Workers are able to provide.

Choose to either fill in our referral online or download the form.

YOUTH DETAILS

Youth Full Name

Date of Birth

Gender

Male Female Other

Address

Youth Contact Number (if applicable)

Youth Contact Email (if applicable)

Ethnicity / Iwi Affiliation

School / Employer Details

WHANAU DETAILS

Parent/Guardian Full Name

Relationship to Youth

Address

Parent/Guardian Contact Number

Parent/Guardian Contact Email

REFERRER DETAILS

Is this a SELF-REFERRAL?

Yes No

Referrer Full Name

Relationship to Youth

Agency

Referrer Contact Number

Referrer Contact Email

Today's Date

REFERRAL BACKGROUND

What is the reason for the referral?

What are the presenting issues/current situation

Are there other agencies involved?

Yes No

If YES, please provide details

Are there any additional comments you would like to include?

*** Important Information – Please Read ***

Please read to ensure you understand CYTs role as mentors, our obligations and sharing of information.

OUR ROLE

Youth Work is the development of a relationship between a Youth Worker and a young person through: connecting with young people; where: young people are empowered, including the choice to engage for as long as agreed; and that: supports their holistic, positive development as taiohi that contribute to themselves, their whanau, community and world.

CONFIDENTIALITY

Your ability to trust the youth worker to hold information in confidence is fundamental to the relationship. When confidences may need to be shared, the youth worker will explain the boundaries of confidentiality.

These boundaries will consider the requirements of your situation/context and our professional practice Limits to confidentiality, which may lead to disclosure, apply when:

• The young person or someone else is in danger
• There is an emergency situation
• It is required by legislation or the courts
• The young person is incapable of consenting.

When information is disclosed, the Youth Worker will endeavour to obtain your permission to seek the appropriate support. Where this is not possible Youth Workers will inform the young person of any disclosure.

Where information is disclosed, only the minimum required for your support should be given. Youth Workers will comply with the Privacy Act 1993, and in particular will ensure collection, storage, access, correction, use and disclosure of information is dealt with in accordance with this Act.

WORKING COLLABORATIVELY

Youth Workers will respect and co-operate with other professionals and/or other significant people involved in the young person’s life to secure the best possible outcomes for the young people they engage with and provide the best support possible.