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Client Referral Form

Please fill out the online form below, by filling in each section and clicking NEXT once you have completed each part.

Or if you would rather fill out the referral form on hardcopy, please click here to download and please email the form to programme Manager Ted Jarvis ted.jarvis@silverfernmotorsport.com or post to PO Box 48156 Blockhouse Bay, Auckland 0644.

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Client Details
Client Risk History
Parent/Guardian Contact Details

Date of Referral *

Referral Source *

Organisation

Self Referral

Family/Whanau Referral

If referral source was an organisation, please state name

Referrer Contact Details

First Name *

Last Name *

Landline

Mobile

Physical Address *

Email

Programme Name for Referral *

Automotive & MotorSport Training & Mentorship Programme (Male)

Young Woman's Training & Mentorship Programme

Drivers License Programme

Client Details

First Name *

Last Name *

Gender *

Age (years) *

D.O.B *

Landline

Mobile

Physical Address *

Ethnicity *

NZ European/Pakeha

Maori - Please enter any iwi affiliations below

Samoan

Cook Island Maori

Tongan

Niuean

Indian

Chinese

Korean

South African

Other

If ethnicity is Maori, please list iwi affiliations below (optional)

If ethnicity is Other, please state below

First Language *

Client is currently employed? *

Yes

No

If currently employed, please state occupation

Please state employer name

Client is currently in the care of CYF Care and Protection? (including with foster parents) *

Yes

No

If Yes Please Provide Details

Client is currently in a CYF Care and Protection Residential Facility? *

Yes

No

If Yes, please write the name of the facility

Client is currently in a Youth Justice Residential Facility? *

Yes

No

If Yes Please Provide Details

Next

Client Risk History

It is essential that all known risks are disclosed whether current or previous.

Please disclose all current and past risks and hazards known about the client:

Drug Use

Has The Client Ever Been Involved in Drug Use? *

Yes

No

If Yes, is this a current risk OR past risk?

Current Risk

Past Risk

Please list any drug assessment reports available

Alcohol Use

Has The Client Ever Been Involved in Alcohol Use? *

Yes

No

If Yes, is this a current risk OR past risk?

Current Risk

Past Risk

Please list any alcohol assessment reports available

Violent or Agressive Behaviour

Has The Client Ever Been Involved in Violent Or Aggressive Behaviour? *

Yes

No

If Yes, is this a current risk OR past risk?

Current Risk

Past Risk

Please list any reports which describe past or current violent or agressive behaviour:

Mental Health Issues

Does The Client Have Any Mental Health issues? *

Yes

No

If yes, please state mental health issues:

If Yes, is this a current risk OR past risk?

Current Risk

Past Risk

Please list any mental health assessment reports for this client:

Other Known Risks

Are There Any Other Risks Not Already Disclosed Earlier? *

Yes

No

If yes, please state other risks:

Does The Client Currently Smoke Tobacco? *

Yes

No

Is The Client Currently on any Form of Medication? *

Yes

No

If Yes, please list medications:

Does The Client Have Past Criminal Offences? *

Yes

No

If Yes, please list all Criminal Convictions and Year Convicted

Is The Client Facing Current Charges with The Court? *

Yes

No

If Yes, please state what charges are being faced:

If Yes, please state any confirmed court dates:

Next Previous

Parent / Guardian Details

Please note that this person will also be the first point of contact in an emergency.

Parent or Guardian? *

Parent

Guardian

If Guardian, please state relationship to client:

Does the Parent or Guardian currently live with the client? *

Yes

No

First Name *

Surname *

Physical Address *

Landline - Please include area code

Mobile

Alternative Phone Number

Second Point of Contact Details

Please provide a second point of contact in case we are unable to reach the primary contact in case of emergency.

First Name *

Surname *

Relationship to client *

Physical Address *

Landline - Please include area code

Mobile

Alternative Phone Number

Please state what the main reason is that the client wishes to come on the programme? *

To complete this referral, please hit "Send Referral Now"

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