OhioRISE Referral Form
Are you referring for yourself or on behalf of someone else?
Myself/My Child
Someone Else
Referral Contact Name
*
First Name
Last Name
Referral Contact Email
*
example@example.com
Referral Agency
*
Doctor's office, county department, etc.
Youth Name
*
First Name
Last Name
Youth Date of Birth
*
-
Month
-
Day
Year
Date
Youth's Legal Guardian Name
*
First Name
Last Name
Youth's Legal Guardian Phone Number
*
-
Area Code
Phone Number
Youth's Legal Guardian Contact Email
example@example.com
Relationship of Legal Guardian to Youth
*
Biological, kinship, agency, etc.
Youth Address
*
Street Address
Street Address 2
City
State
Zip Code
Youth County of Residence
*
Allen
Auglaize
Champaigne
Clark
Darke
Greene
Hardin
Logan
Madison
Miami
Shelby
Other
If you marked "other" what is the youth's county of residence?
Is the youth being referred for a CANS assessment due to a Qualified Residential Treatment Program (QRTP) placement?
Yes
No
How did you hear about NYAP?
Social Media
Google Search
Website
Participant of other NYAP program(s)
Friend Referral
Pamphlet or Flyer
Professional Referral
Please verify that you are human
*
Click Submit Below to Complete
Once completed, your referral will be processed within 24 business hours. You will be contacted by a National Youth Advocate Program (NYAP) team member. Thank you so much for your inquiry.
Submit
Should be Empty: