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Community Connections YouThrive Referral

Referral Details
Youth First Name*
Youth Last Name*
Youth Preferred Name
Youth Birth Date Calendar
Race & Ethnicity
Sexual Orientation  
Youth Phone Number
Enter Int'l Number
Youth Email
Child County of Residence
Current Placement Name
Relationship to Placement
Current Placement Phone Number
Enter Int'l Number
How would you describe the youth's stability at their current placement?  
Case Information
County Where Client's Case Resides  
Case Manager*
Case Manager Work Phone*
Enter Int'l Number
Case Manager Email
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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