Project Avary Third-Party Referral Intake Form
Do you know of a child who would benefit from Project Avary's programming? Please complete the following information and an Avary staff will follow up with a phone call for more details.
This form should be filled out by the child's teacher, counselor, social worker, coach, therapist or someone who is knowledgeable about the child's behavior outside of the home. This person should NOT be a family member.
Referral Guidelines:
Please consult our website for information about eligibility:
http://www.projectavary.org/refer-a-child/
Your Name (referring party): *
Your answer
Your relationship to child: *
Required
Referring Agency, Organization or School: *
Your answer
Referring Party's Phone Numer: *
Your answer
Referring Party's Email: *
Your answer
Child's First & Last Name: *
Your answer
Child's Age: *
Child's Grade in School: *
Your answer
Child's Caregiver: *
Your answer
Caregiver Relationship to Child *
Required
Caregiver's Phone Numer: *
Your answer
Caregiver's Email:
Your answer
Language(s) spoken in the child's home: *
Required
Do the caregiver and/or child know about the program? If so, what are their thoughts about being potentially involved? *
Your answer
How is the child's attendance at the school/sport/appointment, etc where you know the child? *
Required
What is the relationship of the incarcerated family member(s) to the child? *
Required
To your knowledge, is this family member currently incarcerated in a State or Federal prison, or a County jail? Please choose all that apply. *
Required
To your knowledge, does the child have contact with this family member? *
Required
Why do you think this child would benefit from being a part of Project Avary? *
Your answer
How would you describe the child's temperament? Please check all that apply: *
Required
How much ADULT supervision does the child needs? Please check all that apply: *
Required
Are there any behaviors where the child needs adult supervision? Please check all that apply: *
Required
How does this child handle new environments/experiences/people? *
Required
Please share the child's strengths: *
Your answer
Please share any potential concerns you may have about the child's behavior, his/her relationships with peers or otherwise? *
Your answer
How would you describe the child's friendships and relationships with peers? Lots of friends? Few friends? *
Your answer
If the child is upset, how does he or she react? Please be as specific as possible. *
Your answer
In the past year has the child gotten into any physical fights with other children? If so, please explain. *
Your answer
To your knowledge, please share how the child is doing in school. Please be specific. *
Your answer
To your knowledge, in the past year, has the child been suspended and/or expelled from school? Check all that apply... *
Required
To your knowledge, has the child EVER been suspended and/or expelled from school? Check all that apply... *
Required
Please explain any boxes related to school discipline.
Your answer
Is there anything else you think we should know in order to best serve the child and their family? *
Your answer
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