SE Network | Referral
Questions? Contact our Intake & Referral Specialist at 206-258-1909
Referral Date (Today's Date):
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/
Month
/
Day
Year
Date
Participant Information
Eligibility:
Resides in SE Seattle
Attends school in SE Seattle
Connected to SE Seattle
Participant Name:
*
First Name
Last Name
Participant Age:
*
Participant Gender:
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Male
Female
Nonbinary
Other, specify:
Participant School Status:
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Enrolled
Unenrolled
Enrolled for GED
Obtainted GED
Graduated
Running Start
Other, specify:
Participant Grade:
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N/A
6
7
8
9
10
11
12
Other, specify:
Participant School Name:
*
Unsure
N/A
Aki Kurose Middle School
Alan T. Sugiyama High School at South Lake
Cleveland High School
Franklin High School
Interagency Academy
Mercer Middle School
Orca K-8
Rainier Beach High School
Rainier Valley Leadership Academy
South Shore K-8
Washington Middle School
Other, specify:
Participant Race/Ethnicity:
*
Unsure
African Immigrant
American Indian or Alaskan Native
Asian Indian
Black/African American
East Asian (Japanese, Chinese, Korean, etc.)
Hispanic/Latino
Arab/Middle Eastern
Multi-Ethnic
Native Hawaiian/Pacific Islander
Southeast Asian (Cambodian, Vietnamese, Thai, etc.)
White
I choose not to answer
Other, specify:
Participant Phone Number:
Please enter a valid phone number.
Participant Email:
example@example.com
Participant Address:
Street Address
Apt #
City
State
Zip Code
Does youth/young adult know you are making this referral?
*
Yes
No
Is youth/youth adult willing to participate?
*
Yes
No
Presenting Barriers
Criminal Legal System
History of criminal activity/involvement
On probation or court involved
Has been convicted multiple times and released from supervision OR is under minimal supervision and is at risk to re-offend
Has been arrested for crime(s) that do not meet the juvenile detention intake criteria and was released
JUVIS # and Probation Officer:
School
Low achievement/failing core subject
Truancy issues (absent 9+ days per semester)
Suspension/expulsion from school for violence
Suspension/expulsion from school for nonviolence related issue
Has an IEP or 504 plan (specificy in circumstances text box)
Relationships
Association with negative peer group
Association/involvement with gangs
Dating or domestic violence
Drug and Alcohol
Drug use
Alcohol use
Family
Possible drug/alcohol abuse in the home
Incarcerated parent(s) or close relative(s)
Foster care
Unstable housing or homeless
Mental Health
Appears depressed
Anxious or worried about their future
Difficulty coping with challenges
Difficulty controlling impulses/easily distracted
Lack of support network
Aggression
Believes physical aggression is appropriate
History of aggressive, violent behavior
History of carrying a weapon
Employment
Employed
Not employed
If employed, specify where:
Services the participant is currently receiving (e.g., case management):
Brief statement of concern/current circumstance of the participant:
Services the participant may need:
Case Management
Mentoring
Youth Development Programs
Job Readiness
Recreation
Tutoring
School Re-entry
Street Outreach
Peacemaking/Healing Circles
Drug/Alcohol Treatment
Mental Health Services
Parent/Guardian Information (required for referrals under 18)
Parent/Guardian Name:
First Name
Last Name
Relationship to Participant:
Mother
Father
Legal Guardian
Grandparent
Aunt or Uncle
Other, specify:
Parent/Guardian Address:
Same address as participant
Other, specify:
Parent/Guardian Phone Number:
Please enter a valid phone number.
Parent/Guardian Email:
example@example.com
Parent/Guardian Primary Language:
English
Other, specify:
Does this parent/guardian know you are making this referral?
Yes
No
Do not notify parent/guardian
Referral Source Information (How did you hear about us?)
Referral Source Name:
*
First Name
Last Name
Referral Source Phone Number:
Please enter a valid phone number.
Referral Source Email:
example@example.com
Relationship to Participant:
*
Self
School (counselor, teacher, etc.)
Parent/Guardian
Family other than parent/guardian
Friend
Law enforcement/Courts
Community Member
SE Network/BGCKC staff
Other, specify:
How did you hear about SE Network?
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My place of employment (school, community org, etc.)
My counselor, teacher, or someone else from my school
My parent/guardian or other family
My friend
I was a previous participant and looking to reengage
SE Network/Boys & Girls Club Staff
Other, specify:
Submit
Should be Empty: