Make a Referral

Do you know someone or have a client who could use our help? Use the form below to refer them to us. (This form can also be a self referral, if you need help)

Your Name

First

Last

Relationship to person you are referring

How did you hear about us?

Who are we calling back?

First

Last

Relationship to youth / client

Phone

Alternate Phone

Parent is aware of call?

Youth is aware of the call?

OK to leave message?

Youth being referred

First

Last

Gender

Male
Female
Non-binary / other

Date of Birth

Age

Are you working with anyone from the Probation Office?

If yes, why?

List crimes, if any, with pending, prior, or current

Are you working with anyone from the DHS/ Child Welfare

If yes, why?

What led to you contacting us today?

Does the youth have drug/ alcohol issues?

If yes, explain

Have they had any counseling, evaluations, or diagnosis?

If yes, explain

Is there a history of mental health issues or suicidal behavior

If yes, explain

Are they safe?

If no, explain

Any other information that would be helpful? Such as what services are needed (i.e. mediation, shelter)

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Facebook
Instagram