Youth Resource & Referral Form
WE ARE CONTACTING ALL ORGANIZATIONS, PROGRAMS OR PRIVATE THERAPISTS THAT PROVIDE ANY TYPE OF MENTAL HEALTH SERVICES & SUPPORTS FOR... YOUTH AGES 10-25 and/or PARENTS. We realize that many orgs have many programs... for this form, we only want to list the ones relevant to youth mental health, ages 10-25
ORGANIZATION *
If this is an individual (ie: therapist), list as: THERAPIST-Name (THERAPIST-Jane Smith)
Your answer
WEBSITE *
Your answer
NAME *
Name of individual at the organization providing the information for this form?
Your answer
TYPE *
Is this organization a NP (non profit}, BIZ (business), private therapist, school, hospital, doctor
Required
SPECIALTY *
What is your organizations primary area of focus? CHECK ALL THAT APPLY.
Required
TRAININGS, SPEAKERS, CURRICULUM *
DO YOU HAVE SPEAKERS FOR PARENT NIGHTS, CLASSROOMS, ETC? DO YOU OFFER TRAININGS FOR PARENTS, STUDENTS OR PROVIDERS? DO YOU PROVIDE CURRICULUM FOR THE CLASSROOM?
Required
CO-LOCATE SERVICES *
Do you have the ability to co-locate any of your programs or services in other spaces to create easier access for youth and parents? (ie: offer your program on a school campus or more centrally located location?)
REFERRALS *
Do you track your referrals to see if you client was able to access? How do you learn about other resources for your clients?
Your answer
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