Sign up here! | R13Youth Development

To refer a young person to R13 Youth Development Trust, please complete the form below or visit our document library for a downloadable form.

For any questions or concerns, please contact claire.harvey.r13@gmail.com.

All information provided will be treated as strictly confidential and managed in accordance with our privacy obligations.

If you are a young person or parent who is self-referring; please skip the first section and start at details of young person field.

Does the young person and their parent, guardian or caregiver know this referral is being made and do they agree to engage with R13 Youth Development Trust?

Referrer Details

Organisation

Role

Phone number

Young person's full name

Preferred Name *

Ethnicity and Iwi

Phone number

Current school, course or employment

Date of birth

Address(s)

Reason for Refereral. Providing as much detail as possible will assist R13 in assessing and responding to this referral in a timely manner.

Primary Caregiver's name

Ethnicity/iwi

Phone number

Relationship to young person

Address(s)

Secondary Caregiver Name

Relationship to young person

Phone number

Ethnicity/iwi

Address(s)

Others professionals involved. Please provide contact phone and email.

What changes or improvements would you like to see as a result of this referral to R13?

Your form has been submitted!

professionals

Refer yourself or a young person