Cater 2 You Referral Forms

Referring Agency Information
Agency Name:
Agency Contact Person:

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Referral

MonthDayYear
Date

Youth Information
Name

First NameLast Name
Preferred Name/Nickname (if any):
Date of Birth

MonthDayYear
Date
Age
Gender Identity

MaleFemaleNon-binaryOther
Please specify:
Preferred Pronouns:
Race/Ethnicity:
Legal Guardian Name:

First NameLast Name
Guardian Contact Number:
Please enter a valid phone number.

Medical/Mental Health Information
Is the youth prescribed medication?

YesNo
If yes, please list:
Any known allergies or medical conditions?
Behavioral health diagnosis (if applicable):
History of substance use or current treatment involvement?

YesNo
If yes, please explain:
Is the youth receiving therapy or psychiatric care?

YesNo
Provider Name/Agency

Legal & Placement Details
Legal Status:

DependentDelinquentSharedOther
Please specify:
Current Placement Type:

Foster HomeShelterResidentialKinshipOther
Please specify:
Reason for Referral to Cater 2 You Youth Haven:

Education Status
Current School:
IEP or 504 Plan in Place?

YesNo
Last Grade Completed:
Special education needs?

YesNo
If yes, explain:

Service Needs & Goals
What are the youth's service needs or desired program goals?

Emergency HousingLife Skills TrainingMental Health SupportJob Readiness/EmploymentEducation SupportMedical/Dental CoordinationConflict Resolution/ Behavior ManagementOther
Please specify:

Additional Notes/Considerations
Does the youth have any known triggers or safety concerns?
Is the youth a danger to self or others?

YesNo
If yes, explain:
Any history of AWOL (runaway behavior)

YesNo
Any pending court dates or legal obligations?

YesNo
If yes, list dates:

Signature

By submitting this referral, the referring agency affirms that all information provided is accurate to the best of their knowledge.
Referring Worker's Signature:

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Date

MonthDayYear
Date
Supervisor's Name & Contact (if applicable):

First NameLast Name
Should be Empty: