Family Peer Support Referral

If you have any questions regarding this form, please email: nbadell@saltlakecounty.gov

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

Is this a self-referral?

Yes

Client Information

Child's name

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

Child’s DOB:

mm/dd/yyyy

Preferred Language

English

Spanish

French

Other

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

Special Ed Teacher's Name/Phone #:

Therapist's Phone Number:

School Social Worker's Name/Phone #:

Court/DCFS

Child's probation officer:

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