Pro Se Potential Referral
TODAY'S DATE
/
Month
/
Day
Year
Date
YOUTH INFORMATION
Geder Identity
Transgender
Gender Identity
Male
Gender Identity
Other:
Gender Identity
Female
Last Name
First Name
Middle Initial
Address
Street Address
Street Address Line 2
City
State / Province
Zip Code
Date of Birth
/
Month
/
Day
Year
Date
Age
Home Phone
Cell Phone
E Mail
example@example.com
Who does the youth live with?
Both Parents
Mother
Father
Other Relatives
Foster Parents
Other Relatives
Boy/Girlfriend
Couch Surfing
Group Home
Grandparent(s)
Shelter
Streets
Friend(s)
School Name
Grade
Student ID#
Enrolled
Graduated
Expelled
Suspended
Missed Days This Semester
Graduated
Not Attending
GED Program
Enrolled
Youth is currently receiving other services, please list agency name and specify type of service e.g., case management, mentoring, etc:
Yes
Is the youth involved in any activities?
Sports
Leadership
Job
Arts
Music
Cultural
Faith Based
Pro-social
Volunteer/Service Learning
Parenting
Sibling Care
Other Activity:
Recreation
How does the youth identify Race/Ethnicity: (select all that apply and specify if necessary)
Black or African-American
American Indian or Alaskan Native
Asian
Don't know
Multi-racial
Hispanic or Latin
Native Hawaiian or Pacific Islander
White
Refused
PARENT/GUARDIAN INFORMATION
Name
First Name
Last Name
Relationship to youth
Contact phone
Alternative phone
E mail
example@example.com
Does parent know you are making a referral?
Yes
No
Do Not Notify Parent
Does parent need an interpreter?
Yes
No
If yes, what language?
REFERRAL SOURCE INFORMATION
Does youth know you are making this referral?
Yes
No
Is youth willing to participate?
Yes
No
Not Sure
Name
Phone
Email
example@example.com
Administrative Section-Do not write in this section-
Assigned Contact Support
phone contact
Email
example@example.com
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.
Work Domain
Young Person is interested in Communication Skills, Conflict Resolution/ Circle Mediation, Family Integration, Intimacy and Support aka What Love Looks Like.
Relationship Domain
Young Person is interested in Physical Activity, Diet and Nutrition, Behavioral Health, Lifestyle and Sexuality.
Health Domain
Young Person is interested in LIteracy, Credentials, Learning Skills, Career Planning and GED, Diploma and College.
Education Domain
Young Person is interested in Civic Engagement, Community Leadership, Service, Responsibility and Restoring Connections to their Home or Broader Community.
Community Domain
Young Person is intersted in Personal Expression, Visual Arts, Performing Arts, Language Arts, Music and etc...
Creativity Domain
Brief statement of concern and youth's current circumstances.
Youth's Strengths.
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