Youth & Family Connections Referral Form
Is this case of significant risk (i.e. involves suicidal ideation, substance abuse, etc.)?
Yes
No
If yes, please explain:
Youth Information
Youth Name
First Name
Middle Name
Last Name
Gender
Female
Male
Other
DOB
-
Month
-
Day
Year
Date
Age
Race/Ethnicity
African American/Black
American Indian/Alaskan Native
Asian
Caucasian/White - Non Hispanic/Latino
Caucasian/White - Hispanic/Latino
Multiracial
Native Hawaiian/Pacific Islander
Youth School Attending/Last Attended
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency & Case Number (if applicable)
Current Supports In Place
Select all that apply - for youth or family - to the best of your knowledge.
School Based Supports
Counselor
Social Worker
FAST
School Resource Officer
Interventionist
Other
Other Supports
DHS/COMPASS
Probation/Pre-Trial Services
Mental Health
Community Programs (mentorship, respite, etc)
Legal/Courts/Judicial
religious Program Involvement
Other
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email (if available)
example@example.com
Address (if different from youth)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Agency Information
Referring Agency
Point of Contact Name
Point of Contact Title
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Reason for Referral/Notes/Comments
Submit
Print Form for your Records
Should be Empty: