1105 West Front Street Bloomington, IL 309-827-0377 projectoz@projectoz.org
Youth Initiative Program Referral Form
Project Oz works with runaway, locked out, and homeless youth in McLean and Livingston counties. We serve ages 10-17 that are not in the care of DCFS and that plan to remain in the community. We do not discriminate and can meet in a location that best serves the youth and family. Please use this referral form if you work with a youth (under 18) who may be in need of Project Oz services.
Date
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Month
-
Day
Year
Date
Referring Individual/School/Contact Number:
Youth Name
First Name
Last Name
Date of Birth:
Age:
Gender:
Sexual Orientation:
Race:
Youth Contact Information:
Parent/Guardian Name:
Parent/Guardian Contact Information:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the youth currently residing with legal guardian?
If the youth is not residing with legal guardian, who are they living with?
Presenting Issues (Select all that Apply):
Runaway
Lock-out
Truancy/School Conflict
Family Conflict
Pregnant Teen
Behavioral Concerns
Housing/Guardianship
Substance Abuse
Mental Health
Physical Health
Peer Conflict
Formal Station Adjustment
Informal Station Adjustment
Youth on Probation
Youth on Parole
Committed Delinquent Offense
Risk of Violating Probation
DV Against Guardian/Other
Suspensions/Expulsions
Additional Comments:
Submit
Should be Empty: