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The R13 Youth Trust
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If you are a young person (or someone from their whānau) who requires support from
R13 please fill out this form below.
If you are a professional (ie; teacher, counsellor, social worker etc) who wishes to make a referral please complete
the form below
or
visit our
document library
for a downloadable community referral form.
PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE.
Young person's full name
That's me
I'm submitting this form on behalf of them
Ethnicity/Iwi
Date of birth
Phone number
Email
Is there any message you'd like to add to this? You can tell us about you, what's been happening, and what you want from R13 or you can leave it for a korero later. We will get in touch soon! You can also tell us if you prefer text, phone, or email, and when's a good time to call.
Send
Your form has been submitted!
If you are a professional who wishes to refer a young person to
R13
please complete this form
or
visit our
document library
for a downloadable community referral form
. Please do give us an email or call too if you have any questions!
If
you're a young person or someone from their whānau you can absolutely fill out this form if you wish, however you may prefer to complete the form above.
PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE.
The young person and their parent/guardian/carer know this referral is being made and have agreed to give R13 a go
Referrer's name
Organisation
Role
Phone number
Email
Young person's full name
Preferred Name *
Date of birth
Ethnicity/iwi
Phone number
Current school/course/ employment
Address(s)
Parent/caregiver full name
Relationship to young person
Phone number
Ethnicity/iwi
Address(s)
Parent/caregiver full name
Relationship to young person
Phone number
Ethnicity/iwi
Address(s)
Others involved. Please provide contact details!
Please provide details/background around why you are referring this young person to R13.
What are the outcomes you want to see this young person achieve with R13?
Send
Your form has been submitted!
professionals
Sign yourself up or refer someone to R13 here
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