You Are Enough, LLC
Pathway to Wellness
Information about Person Completing Referral
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Individual Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Email
example@example.com
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
Is Individual aware of this Referral?
Yes
No
Type of Services Needed
Adult
Child
Adolescent
Youth to Young Adult Transition
How can I help?
Child/Adolescent Outpatient Services
Youth to Young Adult Transition
Women Issues
Men Issues
Relationship issues
Parent/child conflict
Counseling for mental health
Trauma informed care
School Name
Parent/Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Specify service Individual is considering (Adult)
Individual Therapy
Family Therapy
Youth to Young Adult Transitions
Women Issues
Men Issues
Parent/Child Conflict
Counseling for mental health
Child /Adolescent Outpatient Services
Individual Gender
Male
Female
Other
Individual Primary Language
English
Spanish
Other
Reason for Referral
Current Medications
Select all applicable challenges below for the Individual referred (check all that apply)
Anger
Anxiety
Daily living skills
Depression
Grief
Impulsive Behaviors
Life Skills
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Sustainable employment
Trauma
Whole Health/Wellness
Youth to Young Adult Transition
Other
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