Referral Form

Use this form to refer any person(s) you know that want to work with the OnePercentProgram. Please be advised we are a fee for service.

This field is for validation purposes and should be left unchanged.
Name(Required)
Email(Required)
Please input the details of the young person you are referring.
Name(Required)
(optional, for cultural safety)

Section 3 Young Person Details

What challenges is the young person experiencing?
What challenges have you identified(Required)

Section 4 - Consent

Has the young person agreed to this referral?(Required)
Parent/guardian consent? (if under 18)(Required)

Section 5 - Preferred support

Select your favourite type of support.(Required)

Media Policy

I understand that during activities or services, photographs, video, or audio recordings may be taken for promotional, reporting, or educational purposes.
Tick the box

Consent to Share Information

I have discussed this referral with the client / participant, and they have provided consent for their information to be shared with the receiving organisation / service.
Tick the box(Required)