TRAILS Ministries Youth Referral Form
TRAILS Program Request:
DOVE
Virtual Visitation / Aftercare Mentoring
FYI Mentoring
STAY Housed
IL Work Experience
Job Training Work
Project ID
Girls Group
TRAILblazers After School
TRAILbreakers After School
Referred by:
First Name
Last Name
Referral Contact Information
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Referral Date:
-
Month
-
Day
Year
Date
Referring Agency:
Referred Young Adults Legal Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Gender
Please Select
Male
Female
Nonbinary
Social Security #
Race:
Caucasian (White)
African American (Black)
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Are you Hispanic or Latino
Yes
No
Young Adult's Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Young Adult's Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Mental Health Concerns:
D/A (Drug & Alcohol) Concerns:
List of household members and their relation to Young Adult:
School District
Please Select
Aliquippa
Ambridge
Beaver Area
Big Beaver Falls Area
Blackhawk
Central Valley
Freedom Area
Midland Borough
Rochester Area
South Side Area
Western Beaver
Grade
IEP?
Please Select
YES
NO
Medical Conditions:
Does Young Adult have children?
Please Select
YES
NO
If YES: Names and Ages of Children:
Biological Mother's Name:
First Name
Last Name
DOB (Date of Birth)
-
Month
-
Day
Year
Date
Social Security #
Address (If Different of Referred)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Biological Father's Name:
First Name
Last Name
DOB (Date of Birth)
-
Month
-
Day
Year
Date
Social Security Number:
Address (If different of Referred)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caretaker's Name
First Name
Last Name
Relationship to Youth
Caretaker's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Caretaker's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Probation Officer:
First Name
Last Name
Date of Placement Entrance:
-
Month
-
Day
Year
Date
Date of Discharge from Placement
-
Month
-
Day
Year
Date
Risk Assessment Score/Level:
CYS Caseworker(s)
Independent Living Case Worker:
Other Services & Supports Involved:
Reason for Referral: Why would you like TRAILS to be involved with this family?
Other Known needs of the family:
Dietary Restrictions / Preferences
Submit
Should be Empty: