Refer a Girl

First Name

Last Name

Gender

Birthday

Race

Race Language

The client speaks english

Family Backbround

Parent/Guardian Name

Parent/Guardian Relationship

Parent/Guardian Email

Parent/Guardian Phone

Street

City

State

ZIP code

What is the primary language spoken in the home?

Describe Behavior at Home

Are there any other details about the youth's family you can share?:

Health Information

List any current medical problems

List any medications

Does client have medicaid?

The client has medicaid

List Mental Health Diagnoses:

Risk Factors

has failed a grade-level has failed a class/course is experiencing anxiety/depression/mental health issues is truant from school is gang affiliated is gang involved is sexually active has excessive dependence on her parents has experienced neglectful or poor parenting has runaway from home (at some point) displays aggressive behaviors has poor social skills has behavior problems at school has attempted suicide or has suicidal ideations has been physically/mentally/sexually abused has experienced human trafficking/child porn/prostitution has a history of fire setting Has been/is involved in the juvenile justice system has a history of self harm/mutilation current/past substance use has poor peer associations is withdrawn is/has been involved with CPS impulsive/risk taking parent/sibling convicted of a crime

School Information

Current Grade Level:

School

Describe Behavior at School

How many times has this youth been expelled from school?

How many long-term suspensions has this student received?

How many times has she been suspended from school?

How many school days has this student been absent from school (this year)

How many school days was this student absent from school LAST school year)

This student has an Individualized Education Plan

Referral Source

Referral Name

Referring Organization

Referral Phone

Referral Email

Support Systems

What kind of support systems does this youth have in place?:

What other community programs is this youth involved?

Please provide the youth's therapist name & contact info if possible

Does adolescent have reliable transportation to and from program?

List 3 reasons you are referring your child

Reason for Referring #1

Reason for Referring #2

Reason for Referring #3

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