Connect TEENS Referral Form

Connect TEENS Referral Form

For professionals referring youth ages 14-18. Please complete all applicable sections.
Youth Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender/Pronouns*
Current Placement *
(Primary home, foster care, group home, etc.)
Referring Agency/Professional Information
Name

First NameLast Name
Title/Role*
Agency*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Program Pathway*

Outpatient Behavioral Health YouthYouth 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 SessionsFamily/Caregiver Support
How did you hear about NYAP?

NYAP Foster ParentNYAP EmployeeAttended a NYAP Town HallQR code led me to the websiteFriend/RelativeNYAP WebsiteFacebookGoogle SearchCommunity EventFlyer/BrochureTraditional Media (billboard, newspapers, television, radio)Other
Additional Information
Should be Empty:

Youth Information