Pathfinders Resources Referral Form
Information about Person Completing Referral
Name
First and last Name
Email
example@example.com
Referring Agency
Phone Number
Please enter a valid phone number.
Individual Information (Person needing services)
Name
First and Last Name
Date of Birth
-
Month
-
Day
Year
Preferred Name
If Applicable
Email
example@example.com
Phone Number
Please enter a valid phone number.
Gender
Please Select
Male
Female
Other
Ethnicity:
Please Select
White/Anglo
Black/African American
Hispanic/Latino
American Indian/Native American
Asian/Pacific Islander
Bi-Racial
Other/Multi-racial
Primary Language:
Please Select
English
Spanish
Other
School Attending/Grade
If Applicable
Type of Services Needed
Adult (18+)
Youth (under 18)
Parent/Guardian Name
First Name
Last Name
Relationship
Best contact number
Please enter a valid phone number.
Email
example@example.com
Insurance Information
Type of Insurance (Medicaid, BCBS, UHC, etc)
Policy ID#
Select services(s) of interest: (check all that apply)
Case Management
Casey Life Skills (Community Based)
Family Therapy (Clinical Service)
In-School Mentoring/Support (School Based)
Group Therapy (Clinical Service)
Tutoring and Academic Performance (Community and School Based)
Individual Therapy (Clinical Service)
Motivational Interviewing (Community Based)
Substance Use services (Clinical Service)
Non-Emergency Medical Transportation Services
Grief and Loss Support (Clinical Service)
Secure Transportation Services
Therapeutic Mentoring (Community Based)
Parental Enhancement (Community Based)
Truancy Prevention/Intervention (Community and School Based)
Truancy Prevention/Intervention (Community and School Based)
Gang Prevention/Intervention (Community Based)
Other
Additional Information (Please complete applicable items)
School History:
Please Select
Has history of suspensions
Has history of expulsions
Has history of school disciplinary problems
Has history of school violence problems
Decline in academic performance
Truant
Criminal History/Status
No Prior History
Pending Adjudication
Currently Incarcerated
Currently on Probation/Parole
Other
Delinquency Indicators
No delinquent behaviors
Behavior/discipline issues at home
Suspected/known drug/alcohol use
Aggressive/anti-social attitude
Runaway
Violent actions
Access to weapons
Other
With 1 being the lowest and 4 being the highest, how would you rate this individual’s level of delinquency (if applicable)?
Gang Indicators
Not gang involved
Admits gang involvement
Sibling of known gang member
Associates with gang members
Frequents known gang area
Wears gang attire
Involved in gang related incident(s)
Gang Related Tattoos/Piercings
Other
With 1 being the lowest and 4 being the highest, how would you rate this individual’s level of gang involvement/association (if applicable)?
Select all applicable challenges below for the Individual referred (check all that apply)
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Gang Affiliation/Involvement
Parent/Guardian Guidance
Other
Reason for Referral/Additional Information
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