Youth Era Referral Form
Please fill out this form to refer a youth or young adult to Peer Support provided by Youth Era. If you are a youth or young adult interested in receiving peer support, you can also fill out this form with your own contact information.
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Today's Date *
MM
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DD
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YYYY
County *
Provider name and organization *
Youth or young adult's name, pronouns, cultural and linguistic needs.  (For example: Isabella Morales, she/her/hers, prefer peer support in Spanish.) *
What is the youth/young adult interested in? Check all that apply.
Please add any comments you wish to share.  
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