Our services

Referrals

NGO youth mental health and alcohol and other drugs services Christchurch referral form

Our Health and Wellbeing team provides counselling and education to young people (age 10-25) in the area of Alcohol and Drug, Depression, Anxiety and Eating Awareness.

We accept referrals from general practitioners (GPs), school counsellors, other social services and self-referrals. There is often a wait list for initial appointments, you will be advised of approximate time when we receive your referral.

Details of client

Date of referral:

Name:

Date of birth:

Gender:

Address:

Contact phone:

Client email:

Family email:

Ethnicity:

Current caregiver/parent details:

Phone:

Referrer details

Name:

Role/organisation:

Phone:

Fax:

Email:

Does family/caregiver know of this referral?

Does the young person know of this referral?

GP details:

Reason for the referral:

Please describe any known mental health difficulties or symptoms (e.g. Depression/Anxiety/other):

Alcohol and drug related problems:

Other agencies involved (e.g. CYFs, Police, School, Counselling service) - Currently or in the past:

Safety concerns (e.g. risk to self or others)

Additional pointers or notes (e.g. Is family supportive of referral? Preferred contact method)

Which service would you like ypur referral to go to? If unsure it will be directed to Community Youth Mental Health in Christchurch

Please tick below.