Fresh Start Youth & Family Services Referral Inquiry Form

Fresh Start Youth & Family Services Referral Inquiry Form
Please complete this referral form for youth being considered for placement at Fresh Start Youth & Family Services. Submission of this form does not guarantee placement. Referrals are reviewed based on program fit, youth needs, safety considerations, and bed availability.
Referral Source Information:
Agency/Organization Name:
Referring Staff Name:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Best Method of Contact:
Youth Information
Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Age:
Gender:
Current County:
Current Placement/Residence:
Current Legal Status / Custody:
Is the youth currently in an active placement disruption or emergency need?
Requested Placement Date:

MonthDayYear
Date
Referral Reason
Primary Reason for Referral:
What are the main concerns or needs leading to this referral?
Please describe the youth’s current challenges, needs, and why referral is being requested at this time.
Behavioral / Safety Information
Has the youth demonstrated behavioral challenges in the last 6 months?
If yes, please check any that apply:
Please briefly describe any behavioral concerns and current level of support needed:
Any known safety concerns for staff, peers, or the youth?
If yes, please explain.
History of running away/elopement?
History of aggression?
History of self-harm or suicidal ideation?
History of fire-setting?
History of substance use?
History of law enforcement involvement / DJJ involvement?
Additional safety or risk information:
Mental Health / Medical Information
Current Mental Health Diagnosis(es), if applicable
Current Medications:
Medication Management Needed?
Current Therapist / Behavioral Health Provider
Psychiatrist / APRN / Prescriber
Any current medical conditions or health needs?
Any allergies?
Any special dietary needs?
Education Information
Current School Status
Current Grade Level:
IEP / 504 Plan?
Educational concerns or support needs:
Transportation needs related to school?
Family / Permanency / Support System
Parent/Guardian Name(s), if applicable:
Primary Family Contact / Approved Contact:
Family engagement appropriate at this time?
Visitation or communication expectations:
Are there permanency goals, reunification goals, or transition goals we should know?
Current Services / Supports
Current services the youth is receiving
Please list current providers/services.
What supports have been successful for this youth?
What interventions or placements have not worked well?
Documents Available
Please indicate which documents are available for review:
File Upload

Cancelof
Placement Logistics
Is this referral urgent?
Preferred move-in timeframe?
Certification / Acknowledgment
I certify that the information provided is accurate to the best of my knowledge and is being submitted by an authorized referral source for placement consideration.
I understand that submission of this referral form does not guarantee admission or placement.
I understand Fresh Start Youth & Family Services may contact me for additional information to assess fit and availability.
Name of Person Submitting Form:
Date Submitted:

MonthDayYear
Date
Should be Empty:

Fresh Start Youth & Family Services Referral Inquiry Form

Please complete this referral form for youth being considered for placement at Fresh Start Youth & Family Services. Submission of this form does not guarantee placement. Referrals are reviewed based on program fit, youth needs, safety considerations, and bed availability.

Youth Information

Referral Reason

Behavioral / Safety Information

Mental Health / Medical Information

Education Information

Family / Permanency / Support System

Current Services / Supports

Documents Available

Placement Logistics

Certification / Acknowledgment