Youth Referral Form This form will provide the necessary information to coordinate resources and serve youth in our community. The pathway of completion begins with filling in the document about the identified youth. Pathway: 1. Communicate with the youth about the service provided by the agency the youth is being referred. 2. Upon agreement with the youth complete the form. 3. Upon receipt of referral, agency will initiate outreach to the youth and/or family. 4. A contact response will be sent to the referring agency within 14 days of referral receipt.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Date of referral *Referring agency nameName of person making referral *FirstLastPhoneEmail *Name of person being referred *FirstLastPhoneAddressAddress Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Is youth between the ages of 16 – 24?YesNoPlease enter your birth date.How does youth identify? *FemaleMaleNon-binaryPrefers not to respondPlease select race and ethnicity *American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhitePlease provide the reason for referral:Provide a brief statement about the client’s situation, how you are working with the youth, and the services youth is being referred to participate in with LITE.Is the youth bilingual, with fluency in English?YesNoPrimary language spoken by client:Primary language spoken by parents/other significant adults.Does the youth have transportation?YesNoIdentify the service that would best help youth.Academic Support (GED preparation, Trades apprenticeship test preparation, coursework assistance)Career Exploration (Earn while you learn about careers and how to host a webinar, interview professionals and share with your peers)Work Experience (Earn while you learn the skills needed by employers, demonstrate skills while you work, learn how to connect your skills with interviewing and resume building)Positive Recreational Activity (Participate in arts, dance, and recreational activities as you learn how to manage positive social relationships, earn points toward activities)Life Skills (Attend sessions where you learn money management, learn about housing, preparing for employment, or how to enroll in college courses.Employment program (part time or full time job placement, career readiness, career exploration, support services)Choose the services that help you discovery your pathway to higher earning potential and adulthood.Is there any additional information for us to know in order to provide services?As the referring entity, I have spoken with the client about the service and programs for which this referral is being made. I have obtained and attached a consent for release of information to discuss this client’s case. I agree to participate in planning and mutually supporting the services for this client toward the achievement of their goals.Please upload a consent to share information (if applicable). Click or drag a file to this area to upload. How did you hear about LITE?WebsiteSubmit
