Youth Referral Form

Referral Form

Ignite Youth Alliance
FAX NUMBER: 772-448-8423
IGNITE is a voluntary no-cost mentoring program that provides services and opportunities for youth involved in risky behaviors, high-risk street activities, or community violence.

The IGNITE team works with young individuals to intervene and prevent risky behaviors and violent activities. Individuals work through mental health struggles to address violence in St. Lucie, Indian River, Okeechobee, and Martin Counties.

Individuals work with staff to build a foundation for a successful future. Staff help individuals make positive community connections, get involved in extracurricular activities, help with tutoring and job readiness, connect with counseling, and offer peer mentorship.
Date

MonthDayYear
Are you in need of an interpreter or accomidations?
If yes, which language or accomidation?
Referrer:
Name
Referring agency:
(School, Parent, Guardian, DOC, DJJ, etc.)
Email of referring person:
Contact number of person referring:
Individuals full name:
First, middle and Last Name
Individuals DOB:
Individuals gender:
Individuals Address:
Consumer Contact Number- Please do not add dashes to the numbers. Add ONLY numbers. :)
Parent/Guardian name:
First and Last Name
Parent/Guardian phone number: *Please only use numbers. Do not add dashes. Thank you :)
History of suspensionsHistory of expulsionsHas a history of school disciplinary problemsHas history of school violence problemsDecline in academic performanceTruant
Attending schoolsNot enrolledHS GraduateGED/Voc Ed ClassesDropped outOther
No prior historyUnknownPending AdjudicationIncarceratedPastPresentOn probationOn parole
YesNo
Explain level of risky behaviors:
Please give as much detail as possible.
Behavior/discipline issues at homeSuspected/known drug/alcohol useAggressive/anti-social attitudeRunawayViolent actionsAccess to weaponsOther
Explain mental health or behavioral concerns:
Diagnosis, behaviors, and circumstances.
Family history of violence, substance abuse Sexual exploitation/traumaFriends ( or significant others) who engage in the problem behavior (Violence, substance abuse), anti-social peersBullying, fighting behavior at school/on streets Academic failure, lack of commitment to school (truancy)Victimization and exposure to street violence/trauma (friends, family members killed)Other
Please detail any other pertinent information we will need about the individual.
Should be Empty:

Referral Form

FAX NUMBER: 772-448-8423