Harbor Referral Form
Date:
*
-
Month
-
Day
Year
Date
Referral source:
*
Please Select
School
Caddo Schools Central Office
Law Enforcement
DCFS/State Agency
Community Agency
Medical Agency
Juvenile Court
District Attorney's Office
Self- Referral
Is this referral at the request of a Shreveport Police Officer?
Please Select
Yes
No
Agency
Is this referral for the Risks of Vaping Workshop
Yes
No
Is THC Suspected?
Yes
No
School
Please Select
A. C. Steere Elementary
Academic Recovery Ombudsman
AMI
Atkins Elementary
Bethune/Oak Park Elementary School
Blanchard Elementary
Booker T. Washington High
Broadmoor STEM Academy
C.E. Byrd High
Caddo Adult Education
Caddo Career & Technology Center
Caddo Heights Math/Science Elementary
Caddo Magnet High
Caddo Middle Career & Technology
Caddo Middle Magnet
Caddo Virtual Academy
Captain Shreve High
Cherokee Park Elementary
Claiborne Fundamental Elementary
Creswell Elementary
Donnie Bickham Middle
Eden Gardens Elementary Magnet
Eighty-First Street ECE
Fair Park Middle
Fairfield Elementary Magnet
Forest Hill Elementary
Green Oaks Performing Arts Academy
Herndon Magnet
Huntington High
J.S. Clark Elementary
Judson Fundamental Magnet Elementary
Keithville Elementary/Middle
Magnolia School of Excellence 6-12
Magnolia School of Excellence - K-5
Midway Professional Development Elementary
Mooringsport Elementary
North Caddo Elementary/Middle
North Caddo High
North Highlands Elementary
Northside Middle
Northwood High
Pathways in Education
Pathways in Education - North Market
Pine Grove Elementary
Queensborough Elementary
Ridgewood Middle
Riverside Elementary
Shreve Island Elementary
South Highlands Elementary Magnet
Southern Hills Elementary
Southwood High
Summer Grove Elementary
Summerfield Elementary
Turner Elementary/Middle School
University Elementary
Walnut Hill Elementary/Middle
Westwood Elementary
Woodlawn High School
Youree Drive Middle Advanced Placement Magnet
Form completed by:
*
Title:
*
Agency Name:
Department:
Please Select
Bossier CW-CPI
Bossier CW-FC
Bossier CW-FS
Caddo CW-CPI
Caddo CW-FC
Caddo-FC
Probation
Detention
FPC
IDD `
Other
Please specify department
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
How many clients in this family are you referring for services.
*
Please Select
1
2
3
4
5
6
Is this an alternative to suspension referral to FINS?
Please Select
Yes
No
Has this referral been court ordered?
Please Select
Yes
No
If not court ordered, has the guardian been made aware that a referral is being made to The Harbor?
Please Select
Yes
No
Before a referral can be submitted, a guardian must be made aware. Please contact the parent, then submit the referral.
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Client 1 Information
Use this section to provide information on the client(s) in need of services.
Is client 1 a child or an adult?
*
Please Select
Child
Adult
Client 1 Name:
*
First Name and Middle initial
Last Name
Client 1 Gender
*
Please Select
Female
Male
Other
Client 1 Date of Birth:
*
-
Month
-
Day
Year
Date
Client 1 Race/ethnicity:
*
Client 1 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client 1 Email:
example@example.com
Client 1 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client 1 School:
Client 1 Student ID:
Client 1 Grade:
Language Spoken by client 1:
Are accommodations needed (Interpretation/communication, etc.)? If yes, please specify.
Do you have the client's current insurance information?
Please Select
Yes
No
Insurance/Medicaid Plan:
Insurance/Medicaid ID#
What services are needed?
*
Mental health services
Medication management
Substance use services
Mentoring (middle-high school)
Tutoring (middle-high school)
Food Bank
Uniform assistance
Physical Therapy services (requires physician referral)
Family/Peer Support
Other
What service(s) is the client currently receiving?
*
What providers have you previously referred client 1 to that the client is not currently working with?
*
Guardian name:
*
Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Client
*
Mother
Father
Grandparent
Fictive Kin (non-related caregiver)
Foster Parent
Other
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Client 2 Information
Is client 2 a child or an adult?
*
Please Select
Child
Adult
Client 2 Name:
*
First Name and Middle initial
Last Name
Client 2 Gender
*
Please Select
Female
Male
Other
Client 2 Date of Birth:
*
-
Month
-
Day
Year
Date
Client 2 Race/ethnicity:
*
Client 2 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client 2 Email:
example@example.com
Client 2 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client 2 School:
Client 2 Student ID:
Client 2 Grade:
Language Spoken by client 2:
What accommodations are needed?
(Interpretation/communication, etc.)
Do you have the client's current insurance information?
Please Select
Yes
No
Insurance/Medicaid Plan:
Insurance/Medicaid ID#
What services are needed?
*
Mental health services
Medication management
Substance use services
Mentoring (middle-high school)
Tutoring (middle-high school)
Food Bank
Uniform assistance
Physical Therapy services (requires physician referral)
Family/Peer Support
Other
What service(s) is the client currently receiving?
*
What providers have you previously referred client 2 to that the client is not currently working with?
*
Is the guardian the same as Client 1?
Please Select
Yes
No
Relationship to Client
*
Mother
Father
Grandparent
Fictive Kin
Foster Parent
Other
Guardian name:
*
Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
Client 3 Information
Is client 3 a child or an adult?
*
Please Select
Child
Adult
Client 3 Name:
*
First Name and Middle initial
Last Name
Client 3 Gender
*
Please Select
Female
Male
Other
Client 3 Date of Birth:
*
-
Month
-
Day
Year
Date
Client 3 Race/ethnicity:
*
Client 3 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client 3 Email:
example@example.com
Client 3 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client 3 School:
Client 3 Student ID:
Client 3 Grade:
Language Spoken by client 3:
What accommodations are needed?
(Interpretation/communication, etc.)
Do you have the client's current insurance information?
Please Select
Yes
No
Insurance/Medicaid Plan:
Insurance/Medicaid ID#
What services are needed?
*
Mental health services
Medication management
Substance use services
Mentoring (middle-high school)
Tutoring (middle-high school)
Food Bank
Uniform assistance
Physical Therapy services (requires physician referral)
Family/Peer Support
Other
What service(s) is the client currently receiving?
*
What providers have you previously referred client 3 to that the client is not currently working with?
*
Is the guardian the same as Client 1?
Please Select
Yes
No
Relationship to Client
*
Mother
Father
Grandparent
Fictive Kin
Foster Parent
Other
Guardian name:
*
Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Client 4 Information
Is client 4 a child or an adult?
*
Please Select
Child
Adult
Client 4 Name:
*
First Name and Middle initial
Last Name
Client 4 Gender
*
Please Select
Female
Male
Other
Client 4 Date of Birth:
*
-
Month
-
Day
Year
Date
Client 4 Race/ethnicity:
*
Client 4 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client 4 Email:
example@example.com
Client 4 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client 4 School:
Client 4 Student ID:
Client 4 Grade:
Language Spoken by client 4:
What accommodations are needed?
(Interpretation/communication, etc.)
Do you have the client's current insurance information?
Please Select
Yes
No
Insurance/Medicaid Plan:
Insurance/Medicaid ID#
What services are needed?
*
Mental health services
Medication management
Substance use services
Mentoring (middle-high school)
Tutoring (middle-high school)
Food Bank
Uniform assistance
Physical Therapy services (requires physician referral)
Family/Peer Support
Other
What service(s) is the client currently receiving?
*
What providers have you previously referred client 4 to that the client is not currently working with?
*
Is the guardian the same as Client 1?
Please Select
Yes
No
Relationship to Client
*
Mother
Father
Grandparent
Fictive Kin
Foster Parent
Other
Guardian name:
*
Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Client 5 Information
Is client 5 a child or an adult?
*
Please Select
Child
Adult
Client 5 Name:
*
First Name and Middle initial
Last Name
Client 5 Gender
*
Please Select
Female
Male
Other
Client 5 Date of Birth:
*
-
Month
-
Day
Year
Date
Client 5 Race/ethnicity:
*
Client 5 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client 5 Email:
example@example.com
Client 5 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client 5 School:
Client 5 Student ID:
Client 5 Grade:
Language Spoken by client 5:
What accommodations are needed?
(Interpretation/communication, etc.)
Do you have the client's current insurance information?
Please Select
Yes
No
Insurance/Medicaid Plan:
Insurance/Medicaid ID#
What services are needed?
*
Mental health services
Medication management
Substance use services
Mentoring (middle-high school)
Tutoring (middle-high school)
Food Bank
Uniform assistance
Physical Therapy services (requires physician referral)
Family/Peer Support
Other
What service(s) is the client currently receiving?
*
What providers have you previously referred client 5 to that the client is not currently working with?
*
Is the guardian the same as Client 1?
Please Select
Yes
No
Relationship to Client
*
Mother
Father
Grandparent
Fictive Kin
Foster Parent
Other
Guardian name:
*
Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Client 6 Information
Is client 6 a child or an adult?
*
Please Select
Child
Adult
Client 6 Name:
*
First Name and Middle initial
Last Name
Client 6 Gender
*
Please Select
Female
Male
Other
Client 6 Date of Birth:
*
-
Month
-
Day
Year
Date
Client 6 Race/ethnicity:
*
Client 6 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client 6 Email:
example@example.com
Client 6 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client 6 School:
Client 6 Student ID:
Client 6 Grade:
Language Spoken by client 6:
What accommodations are needed?
(Interpretation/communication, etc.)
Do you have the client's current insurance information?
Please Select
Yes
No
Insurance/Medicaid Plan:
Insurance/Medicaid ID#
What services are needed?
*
Mental health services
Medication management
Substance use services
Mentoring (middle-high school)
Tutoring (middle-high school)
Food Bank
Uniform assistance
Physical Therapy services (requires physician referral)
Family/Peer Support
Other
What service(s) is the client currently receiving?
*
What providers have you previously referred client 6 to that the client is not currently working with?
*
Is the guardian the same as Client 1?
Please Select
Yes
No
Relationship to Client
*
Mother
Father
Grandparent
Fictive Kin
Foster Parent
Other
Guardian name:
*
Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
What services can The Harbor provide that you have been unable to locate or provide?
*
Please provide a few sentences with an overview of the family circumstances.
*
Please list any additional information that would be helpful in determining the needs of the client. Please provide details. (Background, psychological/medical history, court involvement, etc.)
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Child's Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Submit
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