OFFICIAL YMHFA Referral to Professional (
Submit form for the youth you refer to a professional resource
Number of youth you helped from January-March 2019
Location when you made the referral/s *
Select your best guess as to the high school in your area
I referred a child or youth to a professional listed here?
Refer to the professionals listed below
Reason for the referral
Select the main area of concern or signs that may be related to
Approximate age group of child or youth you referred
Select your best estimated grade level
Your role in working with this child or youth
Select the closest description
Date of Referral
Your YMHFA ID number (optional)
First and Last Initials, last 4 digits of your phone number (example: MG8888)
Your answer
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