Seeds Program Referral Form

Seeds Referral Form

All information submitted is confidential.
Youth Information
Name

First NameLast Name
Age
Birth Date

MonthDayYear
What School does the youth attend?
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Is this form being completed by the parent?

YesNo
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does the youth have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the youth prescribed an inhaler or Epipen? If yes, please explain any instructions.
Almost Done!

We just have a few more questions. All of the following information will be used to ensure that the youth's experience with Seeds makes a lasting impact.
Does the youth qualify for Medicaid or free/reduced lunch?

MedicaidFree/Reduced LunchNo
Does the family reside in housing overseen by the Columbia Housing Authority?

YesNoI'm not sure
Has the youth ever been charged with a criminal offense?

YesNoI'm not sure
Is the youth on probation?

YesNo
Is the youth in foster care?

YesNo
If yes, who is their probation officer?
Type N/A if your teen isn't on probation.
Does the youth display any behavior at home that you're concerned about?
Briefly describe issues in the home.
Did the youth experience disciplinary issues in school this past year?

Write upsIn School SuspensionOut of School SuspensionExpulsion
Use this space to share any concerns about the youth that you may have. As a reminder, this information will be used to support our Seeds Participants.
Is the youth involved in any extracurricular activities? If so, please list them here.
What are some of the youth's strengths?
Does this youth have contact with any other systems or agencies?
Ex: DSS, DJJ, LRADAC, etc.
Which Seeds programs are you interested in referring this youth to?

Mentoring ProgramLife Skills ProgramCounseling ProgramSexual Health ProgramCommunity Service Program
Referral Source Information

Information about the individual completing this form. Do not complete this section if this is a parent referral.
Name

First NameLast Name
Agency
What agency/entity are you with?
Phone Number

Area CodePhone Number
Email
example@example.com
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM CONFIRMING THAT I COMPLETED THIS FORM WITH FACTUAL INFORMATION TO THE BEST OF MY ABILITY. I UNDERSTAND THAT DELIVERING AN ELECTRONIC SIGNATURE WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*
Should be Empty:

Seeds Referral Form

Almost Done!

Referral Source Information