Intensive Prevention Services Referral Form

Intensive Prevention Services Referral Form

Fill out the form carefully for registration
Date*

MonthDayYear
MM-DD-YYYY
Youth must meet ONE of the following criteria to be eligible for IPS Services (Check all that apply):*

Displaying extreme signs of At-Risk BehaviorTruant, chronically Late, or Constantly Cuts classesChronically suspended from school, or expelledChallenges with maintaining healthy relationshipsArrested within the past 12 monthsKnown or Suspected Drug UseFrequently runs away from homeOther
Demographic Information:
Youth Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Race*

African AmericanHispanic/LatinoWhiteAmerican IndianAsianNative HawaiianOther Pacific IslanderMulti-RacialOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Birth Date*

MonthDayYear
Parent/Guardian E-mail*
example@example.com
Parent/Guardian Phone Number*
Parent/Guardian Mobile Number
Does the Parent/Guardian need English translation services?*

YesNo
If translation services are needed, what is the primary language spoken by the Parent/Guardian?
Child Welfare & Juvenile Justice Information:
Is there any current/prior DHS involvement?*

YesNo
Is the youth Court Involved, have been arrested or currently on probation?*

YesNo
Current School*
Grade Level*
ID#
Does the youth have an IEP?*

YesNo
Referral Source*
This can be yourself.
Reason for Referral*
Hobbies / Interests*
Please verify that you are human*
Should be Empty:

Intensive Prevention Services Referral Form

Demographic Information:

Child Welfare & Juvenile Justice Information: