Youth Referral Form

The Youth Program 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 Youth 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

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 :)

School History:

School Status:

Criminal History/Status:

Does the parent/guardian/individual consent to be contacted by Ignite staff for follow up for services?

Explain level of risky behaviors:

Please give as much detail as possible.

BEHAVIORAL/MENTAL HEALTH INDICATORS:

Explain mental health or behavioral concerns:

Diagnosis, behaviors, and circumstances.

Additional Qualifying Referral Criteria:

Other

Please detail any other pertinent information we will need about the individual.

Referral Form

FAX NUMBER: 772-448-8423