3rd Street Youth Center & Clinic: Confidential Therapy Referral Form
Youth Name *
Youth contact phone number *
Does the youth need a Spanish speaking therapist? *
Gender identity *
Ethnicity *
Age: must be between the ages 12-24 *
When is the youth available to meet with a therapist on a weekly basis? *
Please provide days and times.
Does the youth know that a member of our staff will be contacting them? *
Name of referral source *
Relationship to youth *
Referral source contact number and/or email address *
Reason for referral *
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This form was created inside of 3rd Street Youth Center & Clinic.