Make a Referral

Your Information

First Name

Last Name

Phone Number

Email Address

Your agency, school, organization, or relationship to the young person you’re referring.

How and/or where did you meet the young person?

Why are you referring the young person for outreach? Please be as specific as possible about their behavior, interactions, risks/challenges, etc.

First Name

Last Name

Nickname (AKA )

Gender

Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

Mixed

Is it possible for you to provide the young person’s birthdate?

Please provide the young person's birthdate.

Please provide approximate age.

Is the young person now or has previously been on probation?

Is the young person now or has previously been involved with a gang?

Please describe gang involvement.

Are you currently in contact with or know how to reach the young person?

Address

Phone

Thru a friend, family member, school/social services contact, or similar (e.g. name, relationship, phone/email)

Where is the young person living? (e.g. their own place, with family, shelter or shared home, couch surfing, homeless, etc.) Include address if known

Ideas to help us locate the young person. (e.g. school, work, hang-out, thru a friend or relative, etc.)

Does the person being referred qualify for free and reduced lunch?