Family Peer Support Referral

Waitlist Advisory

We are currently experiencing high demand for Peer Support services. There is a waitlist, and the family will automatically be added to the list by completing this referral.

If immediate assistance is necessary, please check the "Yes" box below.*

If you check "Yes" one of staff will reach out to you for additional details.

Yes

No

Is this a self-referral?*

Yes

No

Client Information

Child's name*

Even though we work with the family, we need to identify one child as the client.

Child’s DOB:

Preferred Language*

English

Spanish

French

Other

Insurance:

Primary Parent/Guardian's Name:*

#2 Primary Parent/Guardian's Name

Relationship to client:*

(for Primary Parent)

Bio

Adoptive

Grandparent

Other

Parent/Guardian Phone number:

Parent/Guardian Address:

Please check this box if the client lives at this address.

Parent/Guardian Email:

School Information

Current School

Current Grade

Special Ed Teacher's Name/Phone #:

Therapist

Therapist's Name:

Therapist's Phone Number:

School Social Worker's Name/Phone #:

Court/DCFS

Child's probation officer:

Officer's Phone #:

DCFS Worker:

Case worker's Phone #:

Referral Category*

Mental Health

Substance Use Disorder

Law Enforcement Involvement

Other (provide details in summary below)

Reason for Referral*

Briefly explain the current challenges and needs of the family or the youth. .

Send me a copy of my responses

Waitlist Advisory

Contact Info

Client Information

School Information

Therapist

Court/DCFS