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 assitance is necessary, please check the "Yes" box below.*

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

Is this a self-referral?*

Contact Info

Client Information

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

Sexual Orientation*
Preferred Language*
Race:*
Ethnicity:*
Relationship to client:*

(for Primary Parent)

School Information

Therapist

Court/DCFS

(Treatment Programs, Therapy, In-home Services, Etc.)

Select
Caret IconCaret symbol

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