Referral Type
School-basedCounty/DJJCounty/DFCS

Date

Has the parent or guardian been contacted prior to the submission of this form? (If this is a school system referral the parent or guardian MUST be contacted before submitting this form.)
YesNo

Referral Source Information

Organization/Agency (required)

Name of Referring Person (required)

Title

Primary Email (required) (Must be in name@example.com format)

Phone Number (required) (Enter area code and phone number with no spaces, dashes, or parenthesis example 4041239876)

Mobile Number

Fax Number

Preferred Contact Method
PhoneEmailText Message

Is the youth aware that this referral is being made?
YesNo

Client Information Section

Client's Name (required)

County Of Residence (required)

Gender (required)

Ethnicity (required)

Current Grade Level (required)

Client's School

Current Placement

Biological Parent Information

Date of Birth

Primary Insurance Carrier (required)
MedicaidAmerigroupWellcareCenpaticoCareSourceOther

Name of Insurer (required if "Other" is selected above)

Policy Number (separate multiple entries with commas)

Is the youth currently enrolled in school?
YesNo

Name of Current School (if applicable)

Please provide a list of past schools enrolled starting with middle school and ending at high school if applicable:

School 1 (if applicable)

School 2 (if applicable)

School 3 (if applicable)

Does the youth have an Individualized Education Plan?
YesNo

Does the youth want to obtain his/her GED or HS Diploma?
GEDHS Diploma

What is the career aspiration of the youth?

Is the youth being referred before or after 90 days of discharge?
YesNo

Mental Health Diagnosis

Brief Description of Presenting Issues: (required)

Parent/Guardian Information Section

Parent/Guardian Name (required)

Parent/Guardian Street Address (required)

Parent/Guardian City (required)

Parent/Guardian State (required)
Alabama - ALAlaska - AKArizona - AZArkansas - ARCalifornia - CAColorado - COConnecticut - CTDelaware - DEFlorida - FLGeorgia - GAHawaii - HIIdaho - IDIllinois - ILIndiana - INIowa - IAKansas - KSKentucky - KYLouisiana - LAMaine - MEMaryland - MDMassachusetts - MAMichigan - MIMinnesota - MNMississippi - MSMissouri - MOMontana - MTNebraska - NENevada - NVNew Hampshire - NHNew Jersey - NJNew Mexico - NMNew York - NYNorth Carolina - NCNorth Dakota - NDOhio - OHOklahoma - OKOregon - ORPennsylvania - PARhode Island - RISouth Carolina - SCSouth Dakota - SDTennessee - TNTexas - TXUtah - UTVermont - VTVirginia - VAWashington - WAWest Virginia - WVWisconsin - WIWyoming - WY

Parent/Guardian Email (required)(Must be in name@example.com format)

Parent/Guardian Phone Number (required) (Enter area code and phone number with no spaces, dashes, or parenthesis example 4041239876)

Legal Section

Is client involved in an open or pending court case?
YesNoUnknown

Current Probation Status (required)
ProbationNot on Probation

Probation Officer Name (required only if client is currently on probation)

Probation Officer Phone Number (required only if client is currently on probation)(Enter area code and phone number with no spaces, dashes, or parenthesis example 4041239876)

DFCS Case/Involvement (required)
YesNo

Case Worker Name

Case Worker Phone Number(Enter area code and phone number with no spaces, dashes, or parenthesis example 4041239876)

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