North Star Project Care & Concern Form

North Star Project Care & Concern Form

Thank you for your interest in seeking extra support for yourself/loved one. Please fill out the information below and our Licensed Social Worker will reach out to you/your loved one within 1-3 business days upon receipt between 9am-5pm. If this is a crisis, please call 988 for the Suicide and Crisis Life Line, text HELLO to 741-741, or call (866) 367-6023 for the Hudson County primary crisis and mental health hotline.
If this is a Crisis - Do NOT fill the form and contact immediate assistance listed above.
- If you are not a family member: In an effort to provide the most collaborative wrap-around support, a member of our team will contact you prior to initial outreach to family/youth.
- Name*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email*
  example@example.com
- Relationship to youth being referred*
  N/A if Not Applicable
- Is youth aware of this referral? *
  N/A if Not Applicable
- If you are not a parent/guardian, are they aware of this referral? (N/A if you are parent/guardian)*
- Youth Name*
  
  First NameLast Name
- Youth Email*
  example@example.com
- Youth Phone Number*
  Please enter a valid phone number. Format: (000) 000-0000.
- Youth Gender*
  
  MaleFemaleGender Queer/Non-BinaryPrefer not to answerOther
- Youth DOB*
  
  MonthDayYear
- Youth Pronouns - Ex: He, Him His
- Youth Primary Language *
- Youth Home Address*
  Street, City, State, Zipcode
- Ethnicity:*
- Youth Race *
- Please share what you've noticed or experienced in self/youth being referred. Describe the actions/behaviors that have prompted you to seek help with as much detail as possible.*
- Select all applicable challenges below for the youth referred (check off all that apply)*
  
  Ability to avoid dangers/hazardsDaily Living SkillsAnxiety/StressGriefAnger ManagementCommunity Linkage of ServicesDepressionHygieneImpulsive BehaviorsFood/Housing InsecurityLife SkillsDomestic/Dating ViolenceAcademic/School BehaviorSelf-Advocacy SkillsSelf HarmSeparation IssuesSubstance UseSocial SkillsTrauma/Witnessed TraumaYouth to Young Adult transitionSexual/Gender IdentitySuicidal Thoughts/AttemptOther
- Please note that in order for the principal counselor to support youth as best they can, within the scope of their experience and abilities, we have certain exclusionary criteria for the North Star Project that we use as guidelines for eligibility. This will always be on a case by case basis - individuals/families should still fill out the referral form regardless of how much they may fit into the criteria listed below (Select all that apply):*
  
  Within the last year, there has been a psychiatric inpatient hospitalizationWithin the last year, there have been suicide attemptsWithin the last year, individual has experienced suicidal ideationYouth has been diagnosed with Schizophrenia, Schizoaffective, or PsychosisYouth has a history of violence or sexual assaultYouth requires intensive and prolonged medical care or monitoringYouth has not experienced any of the above
- How did you hear about us?*
  
  Friend or family memberSocial MediaNewsletterSchoolEventOther
- If you selected "other", please describe.
- Acknowledgement
  
  I acknowledge this form is not monitored 24/7 and should not be used in the case of an emergency or an immediate threat to the safety or life of individuals. I acknowledge that in such instances, 911 should be called or I can contact Jersey City Medical Center 24/hr Mobile Response Unit at (866) 367-6023 as well as the listed crisis resources at the beginning of this form.
- Please sign here to confirm:
- Should be Empty:

North Star Project Care & Concern Form

If this is a Crisis - Do NOT fill the form and contact immediate assistance listed above.

Acknowledgement