Connect TEENS Referral Form
For professionals referring youth ages 14-18. Please complete all applicable sections.
Youth Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
State of Residence
*
Please Select
Illinois
Ohio
County
*
Parent or Caregiver Name
*
First Name
Last Name
Parent or Caregiver Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender/Pronouns
*
Current Placement
*
(Primary home, foster care, group home, etc.)
Referring Agency/Professional Information
Name
*
First Name
Last Name
Title/Role
*
Agency
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Program Pathway
*
Outpatient Behavioral Health Youth
Youth in Justice System (probation, diversion, etc.)
Reason for Referral
*
Primary behavioral health or justice-related concerns
Current Diagnoses or Identified Needs
*
Services Requested
*
Group Sessions (21-week program)
Individual Skill-Building Sessions
Family/Caregiver Support
How did you hear about NYAP?
NYAP Foster Parent
NYAP Employee
Attended a NYAP Town Hall
QR code led me to the website
Friend/Relative
NYAP Website
Facebook
Google Search
Community Event
Flyer/Brochure
Traditional Media (billboard, newspapers, television, radio)
Other
Additional Information
Submit
Should be Empty: