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Make It Happen Referral Form
Crown Heights Office: 256 Kingston Ave. Brooklyn, NY 11213
Bed Stuy Office: 423 Gates Avenue, Brooklyn, NY 11216
p. 718.773.6886
neighborsinaction.org/makeithappen
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Email
*
Your email
Referral Source Info
Name/Title of Referral Source:
Your answer
Phone:
Your answer
Referring Agency:
Your answer
Referral Source Type:
*
Self-Referral
Social Service Provider
Center For Court Innovation
Attorney
Social Worker/Case Manager
Community Based Organization
School
Family Member
Other:
Required
Participant Info
Participant Name:
*
Your answer
Age:
*
Your answer
Neighborhood of Residence
Crown Heights
Bed Stuy
Other:
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D.O.B.:
MM
/
DD
/
YYYY
School (if applicable):
Your answer
Grade:
Your answer
Phone #:
*
Your answer
Current Court Involvement:
*
Yes
No
Unsure
Ever Been in Therapy Before:
*
Yes
No
Unsure
Reason for Referral
Briefly Describe Presenting Issues:
*
Your answer
A copy of your responses will be emailed to the address you provided.
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