Youth Referral Form

This field is hidden when viewing the form

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

Referrer Information

Your Name(Required)

First Last

Your Email Address(Required)

Email Address Confirm Email Address

Phone

Preferred Contact Method

Section Break

Youth Information

Your Name(Required)

First Last

Age

Your Phone

Youth Email

School District

Grade/Last Grade Completed

Ethnicity

Gender

Preferred Contact Method

Reason for Referral

Please provide description of youth's situation and needs. Any additional information that might be helpful in placing youth in programs/mentorship.

Is youth in need of urgent crisis intervention services?

Yes

Would you like youth to be considered for our Youth Navigation program?

Yes

Is youth in need of Community Service hours?

Yes

Your Comments/Questions(Required)

Referrer Information

First Last

Release of Information: I understand and acknowledge that the information provided on this form is confidential and may be used by The Foundation WA: Restore and Prepare for the purpose of assessing and providing support to the referred youth. I authorize the sharing of this information with relevant personnel within The Foundation WA: Restore and Prepare who are directly involved in providing services to the referred youth

Date