UAY LGBTQ Crisis Advocacy and Mediation Referral
This form is for referrals where LGBTQ identity is a major part of the reason for the intervention request.
Are you making this referral as a school district staff
*
Yes
No
I have notified the family about this referral and they are expecting a call from UAY staff
*
Yes
No (if no, you must call and notify family before we can follow up)
No, but youth would like to be seen before contact is made because of extenuating circumstances (Note: Permission MUST given after 3 meetings)
Date
*
-
Month
-
Day
Year
Date
Your Name
*
First Name
Last Name
Your email
Your Phone number
*
-
Area Code
Phone Number
Your relationship to the person who needs services
*
Self
Child
Family
Other
Youth Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Pronouns
Gender
Race
Grade
*
School attending
*
Youth Phone Number
-
Area Code
Phone Number
Youth phone ok to:
Text
Leave voicemail
Text & Voicemail
No messages
Parent Name
*
First Name
Last Name
Parent Phone Number
*
-
Area Code
Phone Number
Language barrier (any non-English speakers involved)?
*
Youth
Family
Youth and Family
Not applicable
Preferred language
Family Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Email
example@example.com
Names and ages of Family members involved
Briefly state why you are seeking intervention support
*
For school staff, what interventions have been tried up to this point?
Any other information that might be helpful
Your referral is ineligible because the family has not been notified
You may submit this form, but the family will not be contacted until we have confirmation that they are ready for contact from a UAY staff person.
Submit
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