Refer a Young Person

Thank you for your interest in Youth Up Front engagement programs. We have various levels of funding which have specific criteria. In completing the below form, we will be able to assess your eligibility and provide you with options.

One of our team members will be in touch within 2 business days with a response.

Young Person Details Being Referred

Young Person Name (being referred)
DD slash MM slash YYYY

Details of Person Referring

Name

Basis of Referral

Low Self Confidence / Poor Self Perception?(Required)
Inappropriate or Poor interpersonal Skills?(Required)
Negative interaction with peers?(Required)
Negative interaction with teachers/staff?(Required)
Difficulty coping with changes?(Required)
Poor social skills?(Required)
Poor attendance at school ie 65% or lower?(Required)
Disinterest and poor engagement at school?(Required)
Has the young person had 3 or more short school suspensions?(Required)
Has the young person had any cautions from the local police?(Required)
Does the young person have a criminal record?(Required)
Has the young person had 1 or more long school suspensions?(Required)
How did you find out about our services?(Required)

Consent(Required)