Form Center

2. Date of Referral
3. Referred by
4. Phone
5. Email
7. Youth Status

   Check all that apply.

   1. In adult custody, pending case disposition
   2. Out of adult custody, on Pretrial Release or pending disposition
   3. In Juvenile detention, pending case disposition
   4. Juvenile Court case, pending case disposition
   5. Community Resource Court
   6. In Diversion (DJJ)
   7. Post-Disposition
   8. Youth in school, presenting with behavioral concerns
8. Reason for Referral

   Check all that apply.

   1. Mental Health Assessment and Treatment Recommendations
   2. Substance Use Assessment and Treatment Recommendations
   3. Youth in Crisis (detention, incarceration, lack of housing, family dysfunction)
   4. Case Management/Care Coordination/Referral
   5. For youth in detention/custody only: Counseling, mental health custody issues, medication needs, treatment referrals and discharge planning.
10. Youth Information
12. Name
13. Phone Number
14. Date of Birth
15. School
17. Address
18. Family Member/Guardian Contacts:
20. Interpreter needed for Family Member or Guardian?

    1. Yes
    2. No
21. If yes, what language?
23. Defense Counsel (if applicable)
25. Court Counselor (if applicable)
27. Court Date (if applicable)
29. DSS Social Worker (if applicable)
31. Please provide detail about the reason for referral
33. Additional Documentation or Details

    Note: If you have any documents you would like to submit along with this referral form, please attach them here.

35. Behaviors/Risk Factors

    1. Fighting/Assaultive/ Aggression Issues
    2. Impulsivity/Risk Taking
    3. Alcohol Use
    4. Substance Use
    5. Running Away
    6. Anxiety/Depression
    7. Bullying
    8. Being Bullied
    9. Self-Harming
    10. Suicidality
    11. Trauma
    12. Sexual Abuse
    13. Sexual Issues
    14. Fire Starting
    15. Other
36. If Other, specify:
38. Issues in School
40. Issues in the Home
42. Prior or Current Mental Health/Substance Use Treatment
44. Insurance/Medicaid Information
46. Other Important Contacts
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

* indicates a required field