Child Referral Form for Professionals
* Required
Email address
*
Your email
Referring School/Organization
*
Your answer
Referring Organization's Contact Name/Title
*
Your answer
Contact Phone
*
Your answer
Contact Email
*
Your answer
Custodial Parent/Guardian's Name (first & last)
*
Your answer
Custodial Parent/Guardian's Phone
*
Your answer
Custodial Parent/Guardian's Email
*
Your answer
Child's Name (first and last)
*
Your answer
Child's Living Situation
*
Choose
Two Parent: Married
Two Parent: Not married
Two Mothers
Two Fathers
One Parent: Male
One Parent: Female
Grandparent(s)
Sibling Guardian
Other Relative
Foster Home
Group Home
Other
County where child resides
*
Choose
Addison
Bennington
Caledonia
Chittenden
Essex
Franklin
Grand Isle
Lamoille
Orange
Orleans
Rutland
Washington
Windham
Windsor
Street Address
*
Your answer
City
*
Your answer
State
*
Choose
Vermont
Zip Code
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Gender
*
Female
Male
Prefer not to say
Other:
Child's Ethnicity
*
Choose
American Indian or Alaskan Native
Asian
Black
Hispanic
Multi-race (Asian & White)
Multi-race (Black & Asian)
Multi-race (Black & Hispanic)
Multi-race (Black & White)
Multi-race (Hispanic & Asian)
Multi-race (Hispanic & White)
Multi-race (None of the above)
White
Some other race
Child's School
*
Your answer
Child's Grade
*
Choose
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Does the child have any physical, mental or behavioral challenges?
*
Yes
No
If yes, please explain
Your answer
Does the child receive free/reduced lunch?
*
Yes
No
Unknown
Does the child have a parent in the military?
*
No
Yes: Active Duty
Yes: Retired/Vet
Yes: Deceased
Does the child have an incarcerated parent?
*
No
Yes: Currently Incarcerated
Yes: Previously Incarcerated
Unknown
Does the child have a deceased parent(s)
*
Yes
No
Unknown
Has the child been affected by the opioid crisis?
*
Yes
No
Unknown
If yes, please briefly explain:
Your answer
Which program do you see as most appropriate for the child given his/her/their needs?
*
School-Based: meets once a week at school during the school year (for ages 6-12)
Community-Based: meets 2-4 times per month in the community (for ages 6-18)
Site-Based Plus: primary meeting spot is at school, also meets in the community (for ages 6-12)
Bigs in Blue/Bigs with Badges: children are paired with a police office/badged professional (for age 6--18)
Beyond School Walls: a career-based program (for youth age 14-18)
I'm not sure
Other:
Thank you for your referral! Please ensure that the parent/guardian knows that we will be contacting them to complete a full application.
A copy of your responses will be emailed to the address you provided.
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