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Youth Health Support Service Online Form

CONFIDENTIAL PERSONAL DATA

Please complete or check the appropriate responses regarding the above named young person
Academic Performance
Health
Strengths
Behaviour
Strengths continued
Known substances used
Comments: 
If you are referring a young person please indicate if you:
Have discussed your concern with the young person
Have discussed your concern with a parent/caregiver
Would you like to speak with a Youth Health Support Service member regarding your concern?

Thank you for your concern about our young people and your participation in the Youth Health Support Service process.  Abiding by the Code of Health & Disability Services Consumer Rights, all information will remain confidential.

When you're satisfied there's nothing else to add, hit the submit button to get things underway.

Thanks for submitting! We will be in contact with you.

Office Use Only:      Staff member: .......................................................................................  NHI:  ..............................

PRIMHD:    T08 (Professional - no client)  T42 (just client)    T36 (client and family)    T32 (just family/whanau)
MASH Doc No: 1531                 
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