Referral Form

CLIENT INFORMATION
Youth Services For

Choctaw, Pushmataha and McCurtain Counties

Brandy Krohn Executive Director

410 South F St, Hugo, Ok 74743

121 N. Central Ave Ste D., Idabel, Ok 74745

415 S W 5th St, Antlers, Ok 74523

Main Office 580-326-3382

Idabel Office 580-286-1158

Fax 580-326-3383
REFERRAL TO YS4CPM
Date of Referral:
Client's Name

First NameLast Name
DOB

MonthDayYear
Date
Phone Number

Area CodePhone Number
Address
School
PARENT/GUARDIAN INFORMATION
Parent's Name

First NameLast Name
Parent's Phone Number

Area CodePhone Number
Address
CDIB:

YesNo
REFERRAL MADE BY:
Individual/Agency/DHS/School:
Telephone:
Contact Person:
SERVICES REQUESTED:

Family CounselingLife SkillsSchool Based ProgrammingParenting ProgramsOutreachSubstance AbuseCase Management ServicesCARSTruancy/ School Based ServicesNew Directions Program / FTOPMentoringIndividual CounselingStrengthening Families ProgramOther
Jolt's number (List offense charges) If applicable*
Jolts number
Offenses/Incident prompting Referral:
Please include a copy of Attendance Report for all Truancy Referrals. Click below to attach any documents.
Browse Files

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For your records, please print before your submission.
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