Refer a Child or Teen to Sunflower Haven
Section 1: Referrer Info (Who is making the referral?)
Name
First Name
Last Name
Relationship to the Child (e.g., parent, counselor, school staff, family friend)
Phone Number
Please enter a valid phone number.
Email
example@example.com
Organization (if applicable)
How did you hear about Sunflower Haven?
Please Select
School
Church
Hospice
Social Worker
Online
Other
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Section 2: Child/Teen Info
Childs Full Name
First Name
Last Name
Age
Grade Level
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred language spoken at home:
Please Select
English
Spanish
Creole
Other
Does the child have any emotional, physical, or learning needs we should be aware of?
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Section 3: Family Background
Is the child:
Grieving the loss of a parent or guardian
Coping with a parent who is seriously/terminally ill
Other
Brief explanation of child’s current emotional needs (optional, but helpful):
Is the family currently facing financial hardship?
Yes
No
Unknown
Parent/Guardian Name(s)
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Are there other children in the home who may need support?
Yes
No
Not Sure
Does the family know you’re making this referral?
Yes
No
I’d like help approaching them
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Section 5: Additional Notes & Uploads
Would you like to share any documents that may help us understand the situation?
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Section 5: Permissions & Notes
I confirm that I have permission from the parent/guardian to make this referral.
confirm
Additional Notes or Special Considerations:
Signature
Send to Sunflower Haven Team
Should be Empty: