YouthLink TEAM Meeting Request

YouthLink TEAM Meeting Request
Student Information
Student*

First NameLast Name
Date of Birth

MonthDayYear
Date
What gender does the student identify with?*

MaleFemaleOther
What race/ethnicity does the student identify with?*

HispanicBlackWhiteAsianNative AmericanPacific IslanderMixed
What school does the student attend?

Hagen Early Learning CenterAyres ElementaryCampbell ElementarySterling Middle SchoolSterling High SchoolSIX12 ONLINECalicheMerinoFlemingPeetzGOAL AcademyOther
What grade is the student enrolled in?

PreschoolKindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth
Parent or Guardian Name*
What is this person's role with this child?*

MotherFatherGrandparentOther
Parent/Guardian Phone Number*

Area CodePhone Number
Does the student have siblings that live in the home?

YesNoMaybeOther
Reason for Referral
What concerns are you aware of with this student?*

GradesSchool AttendanceBehavior at schoolBehavior at homeDepression/AnxietyAnger ManagementConflict with other studentsConflict with teachers and/or school staffLack of MotivationDrugs/AlcoholMarijuana useSelf-harm (cutting, food addictions, pornography)Recent traumatic experienceRecent change in lifestyle (moved, divorce, etc.)Other
What circumstances or primary concern prompted this meeting request?*
Service Providers
Please select any service providers that are currently connected with this student

School Counselor/Student Support ServicesMental Health CounselorProbation OfficerCYDC Case ManagerMentorHuman Services Case WorkerFamily Resource Center youth programChurchOther

Please list any specific service providers or support people who should be invited to participate:

	Name	Agency	Email
Person to Invite
Person to Invite
Person to Invite
Person to Invite
Person to Invite
Person to Invite

Referral Source
Your Name
Agency Name
Your role with this student

ParentTeacherSchool AdministratorStudent Support ServicesCommunity-based Service ProviderJuvenile JusticeChild WelfareOther
Screening Needed?

Please read the following descriptions before selecting an option: MEETING ONLY: Choose this option if you already have good background knowledge about the youth and family, and we simply need to set goals, help the youth engage in services, and get everyone on the same page. SCREENING BEFORE MEETING: Choose this option when you are unsure what underlying issues may be going on that are creating difficulties for the youth/family. The YouthLink coordinator will meet with the family (prior to the scheduled meeting) for a screening conversation to gain a better sense of the concerns and what services may be relevant to explore during the meeting.
Would this student benefit from a screening before the meeting?*

MEETING ONLYSCREENING BEFORE MEETINGUnsureOther
Multi-agency Release of Information
Has a multi-agency release been signed for this student?

Yes. (please e-mail to youthlink@youthlinklogan.com)No.The family will sign at the meeting if neededRelease should be initiated by the coordinator during the screeningOther
Meeting Time & Place
Do you have a preference about where the meeting should be held?

SchoolThe AnnexLCDHSFamily Resource CenterCSU Engagement CenterNo OpinionOther
Are there certain days that will work best for you in the next 2 weeks? (select all that apply)

Monday MorningMonday AfternoonTuesday MorningTuesday AfternoonWednesday MorningWednesday AfternoonThursday MorningThursday AfternoonFriday MorningFriday AfternoonOther
Comments
Should be Empty:

YouthLink TEAM Meeting Request

Student Information

Reason for Referral

Service Providers

Referral Source

Screening Needed?

Multi-agency Release of Information

Meeting Time & Place