Sign up here! | R13Youth Development

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

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.

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). 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 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

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?

Your form has been submitted!

professionals

Sign yourself up or refer someone to R13 here