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Referral Details
Youth First Name*
Youth Last Name*
Youth Birth Date Calendar
Youth Phone Number
Enter Int'l Number
Race & Ethnicity
Sexual Orientation  
Current Placement Name
Current Placement Phone Number
Enter Int'l Number
Relationship to Placement
How would you describe the youth's stability at their current placement?  
Case Information
Case Manager*
Case Manager Work Phone*
Enter Int'l Number
Case Plan Goal*  
Expected Date of Release from Care Calendar
Date Client was Released from Care Calendar
Approximately how long have you been working with this youth?*
What goals/tasks are you hoping YOUTHRIVE can help support?
Support Network/Relational Skills:
Financial Capabilities:
Educational/Career Progression:
Other Goals:
Youth History
Please indicate your knowledge of any of the following occurrences in your youth’s past to the best of your ability (NOTE: this information is used to assess for program fit, level of support necessary, and

determine best fit for support families during our matching process).
Hospitalization for psychiatric needs*  
Substance use that needed treatment*  
Suicide attempt, suicidal ideation, or self-harm*  
Violence or physical aggression*  
Criminal charges*  
Current mental health services*  
Please feel free to provide additional comments related to any of the information above
Case Manager's Signature*
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