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If you are a young person (or someone from their whānau) who wants support from R 13 you can fill out this form - or give us an email or text.
If you're a professional (like someone's teacher, counsellor, social worker etc) who wants to make a referral please fill out
the form below
instead (or
visit our
document library
for a downloadable community referral form).
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 wants to refer a young person to
R13
please fill out this form
(or
visit our
document library
for a downloadable community referral form)
. Ple
ase 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 want - but you might prefer to just do the one above!
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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