2018 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
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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. *
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Date of Referral *
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Person Making Referral: *
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Person Making Referral Phone Number: *
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Person Making Referral Email Address: *
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May we contact referral source? *
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Reason for Referral? *
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Youth Name: *
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Youth Gender: *
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Youth Date of Birth: *
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Youth Grade & School: *
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Youth Address: *
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Youth Cell Phone: *
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Youth E-mail: *
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Parent/Guardian Name: *
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Parent/Guardian Phone Number: *
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Parent/Guardian Email: *
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Who is Primary Contact? *
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May we send detailed messages via email/phone? *
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Youth has a 504 plan or an IEP from school: *
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Youth is currently in counseling: *
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If Youth is currently in counseling- Name of Counselor:
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Is there a history of substance use/legal involvement? *
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If yes to a history of substance use/legal involvement please describe:
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If youth is struggling with social, behavioral or mental health challenges that impacts on the transition into education and/or employment, please describe:
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Other information you would like to share:
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A copy of your responses will be emailed to the address you provided.
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