Odyssey House Trust Christchurch
Greers Road site is a smoke free premises
If you would like support to quit smoking please ask your worker about the support available

Please complete and submit the online form. If you prefer, you can download and print out the form with the link below, and once completed post to:

PO Box 34 009
Fendalton
Christchurch 5
Ph: 03 358 2690
Fax: 03 358 2907

Click here to download a printable version

 

Youth Service Residential & Day Programme Referral Form
  1. Name
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  2. Date of Birth
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  3. NHI Number
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  4. Ethnicity
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  5. Phone Number
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  6. Address
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  7. Current Living Situation
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  8. If other please specify
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  9. Current Situation
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  10. Family / Caregiver Contacts

  11. Name
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  12. Phone Number
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  13. Relationship
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  14. Address
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  15. Other

  16. Name of last school attended
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  17. Date left
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  18. Education - reading and writing difficulties
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  19. Alcohol and other Drug Overview
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  20. Medical Issues and medications
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  21. Methadone
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  22. If yes, please specify the dose
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  23. Psychiatric issues
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  24. Risk assessment
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  25. Legal Status
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  26. Probation Officer
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  27. CYPFS Involvment
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  28. Social Worker
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  29. Please tick if the client has been convicted of any of the following:
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  30. Details of convictions
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  31. Court Fines
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  32. Child Support
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  33. Education
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  34. Previous AOD Treatment
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  35. General Comments / Other issues or concerns of note
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  36. Referral Agency
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  37. Referrers name
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