YouthLink TEAM Meeting Request

YouthLink TEAM Meeting Request
Student Information
Student *

First Name Last Name
Date of Birth

Month Day Year
Date
What gender does the student identify with? *

Male Female
What race/ethnicity does the student identify with? *

Hispanic Black White Asian Native American Mixed
What school does the student attend?

Hagen Early Learning Center Ayres Elementary Campbell Elementary Sterling Middle School Sterling High School RE-1 Edge Program Caliche Merino Fleming Peetz GOAL Academy
What grade is the student enrolled in?

Preschool Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth
Parent or Guardian Name *
What is this person's role with this child?

Mother Father Grandparent
Parent/Guardian Phone Number *

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

Yes No Maybe
Reason for Referral
What concerns are you aware of with this student?

Grades School Attendance Behavior at school Behavior at home Depression/Anxiety Anger Management Conflict with other students Conflict with teachers and/or school staff Lack of Motivation Drugs/Alcohol Marijuana use Self-harm (cutting, food addictions, pornography) Recent traumatic experience Recent change in lifestyle (moved, divorce, etc.)
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 Services Mental Health Counselor Probation Officer CYDC Case Manager Mentor Human Services Case Worker Family Resource Center youth program Church

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

Parent Teacher School Administrator Student Support Services Community-based Service Provider Juvenile Justice Child Welfare
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 ONLY SCREENING BEFORE MEETING Unsure
Multi-agency Release of Information
Has a multi-agency release been signed for this student?

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

School The Annex LCDHS Family Resource Center CSU Engagement Center No Opinion
Are there certain days that will work best for you in the next 2 weeks? (select all that apply)

Monday Morning Monday Afternoon Tuesday Morning Tuesday Afternoon Wednesday Morning Wednesday Afternoon Thursday Morning Thursday Afternoon Friday Morning Friday Afternoon
Comments
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YouthLink TEAM Meeting Request

Student Information

Reason for Referral

Service Providers

Referral Source

Screening Needed?

Multi-agency Release of Information

Meeting Time & Place