GET CONNECTED REFERRAL FORM
Helping young people discover and create options to build a successful future. Get Connected is generously supported through a partnership with
Email address *
By completing this online form you understand that a summary of the submission will be sent to you to print, review and submit either electronically or via fax with signatures from the Referral Source, the Parent/Guardian and the Youth. *
Required
Date of Referral *
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DD
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Person Making Referral: *
Person Making Referral Phone Number: *
Person Making Referral Email Address: *
May we contact referral source? *
Required
Reason for Referral? *
Youth Name: *
Youth Gender: *
Required
Youth Date of Birth: *
MM
/
DD
/
YYYY
Youth Grade & School: *
Youth Address: *
Youth Cell Phone: *
Youth E-mail: *
Parent/Guardian Name: *
Parent/Guardian Phone Number: *
Parent/Guardian Email: *
Who is Primary Contact? *
Required
May we send detailed messages via email/phone? *
Required
Youth has a 504 plan or an IEP from school: *
Required
Youth is currently in counseling: *
Required
If Youth is currently in counseling- Name of Counselor:
Is there a history of substance use/legal involvement? *
Required
If yes to a history of substance use/legal involvement please describe:
If youth is struggling with social, behavioral or mental health challenges that impacts on the transition into education and/or employment, please describe:
Other information you would like to share:
A copy of your responses will be emailed to the address you provided.
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