Orange County Breakthrough Referrral
Please answer the following questions about the youth seeking services.
Do they live in Orange County?
*
YES
NO
Do they live at home with parent/caregiver?
*
YES
NO
Is the youth between 9-17 and have there been one or more Baker Acts within the last 12 months?
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YES
NO
Is the youth diagnosed with Autism Spectrum Disorder?
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YES
NO
Has the youth been Baker Acted in the past 12 months?
*
YES
NO
What are the youths documented mental health diagnosis ?
Has the parent/caregiver been made aware of this referral?
*
YES
NO
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Basic Information
First Name:
*
Middle Name:
Last Name:
*
Gender:
*
Please Select
Female
Male
Gender Non-Binary
Transgender Female
Transgender Male
Prefer not to disclose
Birth Date:
*
Age:
Housing Information
Is the youth currently homeless?
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Yes
No
If the youth is experiencing homelessness, what area do they stay in (cross streets/part of town)?
Current Living Situation (if experiencing homelessness):
Please Select
Emergency shelter (including hotel or motel paid for with emergency shelter voucher)
Transitional housing for homeless persons (including homeless youth)
Place not meant for habitation
Other (Please add to Address Notes)
Address Notes (Living Situation Details):
Home Address:
*
Address2:
City:
*
State:
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code:
*
Parent/Guardian Information
First Name:
*
Last Name:
*
Phone Number:
*
Email Address:
Referral Source Information
Referral Source:
*
Please Select
University Behavioral Center
Central Florida Behavioral Hospital
Diversion
Post Adoption
DCF
Child Welfare
DJJ
OCPS
Mental Health Provider
Community
Other
Other:
Referral Source Email:
*
Referral Source Phone Number:
*
How many Baker Acts does the youth have within the last year?
Dates of Baker Acts, and at which hospital?
Insurance/Payment Information:
Diagnosis:
Reason for Referral:
*
Client Documents (ex.: recent assessments/ evaluations, behavior plans, Baker Act documentation)
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