Pro Se Potential Referral

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

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.
Should be Empty:

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Pro Se Potential Referral

YOUTH INFORMATION

PARENT/GUARDIAN INFORMATION

REFERRAL SOURCE INFORMATION

Youth & Referral Source are interested in- (Check all that apply)