Referral Form
Date of Referral
-
Month
-
Day
Year
Date
Location student will be attending
*
Bowling Green
Madisonville
Virtual
Program/Services student will be attending
*
Breathe Youth Arts Program
Mental & Behavioral Health Classes
Substance Abuse Classes
Vaping Classes
Therapy/Counseling Services
Assessment & Recommendation
(Medicaid Only)
Intensive Outpatient Program (Madisonville)
Other
Number of classes student will attend
1
2
3
4
5
6
7
8
9
10
At least 6 classes recommended
Student Name
*
First Name
Last Name
Student Email
example@example.com
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Grade Level
*
4
5
6
7
8
9
10
11
12
Age
*
9
10
11
12
13
14
15
16
17
18
19
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Parent/Guardian Email
*
example@example.com
REFERRAL SOURCE
Referral Source
*
Parent
CDW
DJJ
DCBS
Counselor
Judge
Principal/Assistant Principal
Teacher
Other
Referring City
*
Referring County
*
REFERRAL SOURCE CONTACT INFORMATION
Referrer's Name
*
First Name
Last Name
Phone Number
*
E-mail
*
Position/Title
REASON FOR REFERRAL
Reason for the Referral
*
Mental Health Concerns
Parental Separation/Divorce
Emotional Well-Being
Suicide/Self-Harm
Friends/Peer Relationships
Family Violence
Bullying
Learning Support/Educational Issues
Attendance Issues
Grief and Loss
Anger
Adjustment Issues
Behavioral Concerns
Accommodation Issues
Parental Concerns
Offense
*
Status
Public
Youthful
N/A
Date Diversion Needs to be Completed
-
Month
-
Day
Year
Date
Other reason for referral (Please state below)
Please provide further information regarding this referral:
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