Pro Se Potential Referral
Street Address Line 2
State / Province
Date of Birth
Who does the youth live with?
Missed Days This Semester
Youth is currently receiving other services, please list agency name and specify type of service e.g., case management, mentoring, etc:
Is the youth involved in any activities?
How does the youth identify Race/Ethnicity: (select all that apply and specify if necessary)
Black or African-American
American Indian or Alaskan Native
Hispanic or Latin
Native Hawaiian or Pacific Islander
Relationship to youth
Does parent know you are making a referral?
Do Not Notify Parent
Does parent need an interpreter?
If yes, what language?
REFERRAL SOURCE INFORMATION
Does youth know you are making this referral?
Is youth willing to participate?
Administrative Section-Do not write in this section-
Assigned Contact Support
Page 1 of 2 Implemented May, 2021
Youth & Referral Source are interested in- (Check all that apply)
Young Person is interested in Job Experience, Apprenticeships/ Interships, Job Preperation, Income and Independance.
Young Person is interested in Communication Skills, Conflict Resolution/ Circle Mediation, Family Integration, Intimacy and Support aka What Love Looks Like.
Young Person is interested in Physical Activity, Diet and Nutrition, Behavioral Health, Lifestyle and Sexuality.
Young Person is interested in LIteracy, Credentials, Learning Skills, Career Planning and GED, Diploma and College.
Young Person is interested in Civic Engagement, Community Leadership, Service, Responsibility and Restoring Connections to their Home or Broader Community.
Young Person is intersted in Personal Expression, Visual Arts, Performing Arts, Language Arts, Music and etc...
Brief statement of concern and youth's current circumstances.
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