Carl B. Metoyer Center for Family Counseling
Confidential Referral Form
Who is making the referral?
*
Parent/Guardian
Youth
Youth/Guardian's Case Manager
Youth's School Counselor
Other
Your Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
What contact methods are ok for this contact information?
Phone Call
Voicemail
Text
Email
Unsure
What agency/organization/school are you affiliated with?
What is your job title?
This client/family would benefit from:
*
Couseling
Case Management
Unsure
Other
Youth's Information
Youth's First Name
*
Youth's Middle Initial
Youth's Last Name/Surname(s)
*
Youth's Preferred Name:
Date of Birth
*
-
Month
-
Day
Year
Date
Youth's Email (or put N/A)
*
example@example.com
*
-
Area Code
Phone Number
Youth's Phone Number (or put N/A)
*
Please enter a valid phone number.
What contact methods are ok for this contact information?
*
Phone Call
Voicemail
Text
Email
Unsure
What are the best days/times to contact the youth?
*
Youth's Ethnicity/Race
*
African/African American/Black
Latino(a)/Latinx
White
Asian/Asian American
Pacific Islander
Native American/Alaskan Native
Bi-racial/Multiracial
Unsure
Other
Youth's Language Preference
*
English
Spanish
Unsure
Other
Youth's Preferred Pronouns
*
she/her/hers
he/him/his
they/them
Unsure
Other
Youth's Gender:
*
Cisgender Girl (born female identifies as girl)
Cisgender Boy (born male identifies as boy)
Trans-Femme (born male identifies as girl)
Trans-Masc (born female identifies as boy)
Nonbinary/Nonconforming
Questioning/Unsure
Rather not response
Other
Youth's Sex (assigned at birth)
*
Male
Female
Intersex
Unknown
Other
Is the youth a parent themselves?
*
Yes
They are pregnant or their partner is pregnant
No
Unsure
Other
Youth's Living Situation
*
Parents/Guardians
Homeless/Couch Surfing
Group Home
Foster Care
Unsure
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there anything else that would be helpful to know about the youth's living environment? (Split time between parents/guardians, lives in different friends/families homes, lives at different shelters, one parent/guardian lives further away, etc.)
Parent/Guardian Information
Parent/Guardian First Name (Primary contact)
*
Parent/Guardian Last Name/Surname(s) (Primary contact)
*
Parent/Guardian Phone Number
-
Area Code
Phone Number
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Alternative Phone Number (if applicable)
Please enter a valid phone number.
Does the Alternative Phone Number also belong to the parent/guardian?
Yes
No
Who does the number belong to? (Name/Relationship to Parent/Guardian)
Please note if the alternative phone number belongs to someone other than the above parent/guardian (or put N/A)
Parent/Guardian Email
example@example.com
What contact methods are ok for this contact information?
*
Phone Call
Voicemail
Text
Email
Unsure
What are the best days/times to contact the family?
*
Ethnicity/Race of Parent/Guardian
*
African/African American/Black
Latino(a)/Latinx
White
Asian/Asian American
Pacific Islander
Native American/Alaskan Native
Bi-racial/Multiracial
Unsure
Other
Parent/Guardian's Language Preference
*
English
Spanish
Unsure
Other
Relationship to minor
*
Mother
Father
Aunt
Uncle
Cousin
Family Friend
Other
The parent/guardian prefers to be called
*
she/her/hers
he/him/his
they/them
Unsure
Other
Is the parent/guardian's address the same as the client's?
*
Yes
No
Unsure
N/A
Parent/Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there another parent/guardian for us to contact?
*
Yes
No
Unsure
Parent/Guardian First Name (Secondary contact)
Parent/Guardian Last Name/Surname(s) (Secondary contact)
Phone Number
Please enter a valid phone number.
Alternative Phone Number (if applicable)
Please enter a valid phone number.
Does the Alternative Phone Number also belong to the parent/guardian?
Yes
No
Who does the number belong to? (Name/Relationship to Parent/Guardian)
Please note if the alternative phone number belongs to someone other than the above parent/guardian
Parent/Guardian Email
example@example.com
What contact methods are ok for this contact information?
Phone Call
Voicemail
Text
Email
Unsure
Ethnicity/Race of Parent/Guardian
African/African American/Black
Latino(a)/Latinx
White
Asian/Asian American
Pacific Islander
Native American/Alaskan Native
Bi-racial/Multiracial
Unsure
Other
Relationship to minor
Mother
Father
Aunt
Uncle
Cousin
Family Friend
Other
Parent/Guardian's Language Preference
English
Spanish
Other
The parent/guardian prefers to be called
*
she/her/hers
he/him/his
they/them
Unsure
Other
This parent/guardian lives
*
with the youth
with the other parent/guardian
somewhere else
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Information
School Name
*
Grade
*
Please Select
1st
2nd
3rd
4th
5th
6th
7th
8th
9th (Freshman)
10th (Sophomore)
11th (Junior)
12th (Senior)
GPA
*
I have an exact GPA from the school
I can estimate the GPA
I do not know/I'm not sure
Please enter the GPA
What is your closest estimate?
3.0-4.0 (A's, some B's)
2.0-3.0 (B's and C's)
1.0-2.0 (D's and F's, some C's)
0.0-1.0 (doesn't attend class or minimally participates)
Does the youth attend classes?
*
Always
Almost always
Half the time
Less than half the time
Never or almost never
Unsure
Other
Does the youth have an IEP or 504 plan?
*
Yes
No
Unsure
Other
Reason for Referral/Other Info
Are there any accessibility needs? Such as hearing/auditory, speaking/verbal, sight/visual, or mobility? (Please specify who has what needs)
*
Reason for referral - How can we help? If there are Case Management needs, please specify.
*
Office Use Only
Office Use Only - Date of Referral
-
Month
-
Day
Year
Date
Office Use Only - Referral Source: DPN Funded
Choose One
Community
DA/Truancy
Family, Self
Malabar House
Prop 64 Diversion
School/SARB/SART
Transition Center
Youth Court
Other
Other: Please Specify
Office Use Only - Referral Source: Non-DPN Funded
Choose One
RJOY
Other
Other: Please Specify
Office Use Only - Service Type
Please Select
Counseling
Case Management
Crisis Receiving Home
Diversion/Prop 64
Truancy Mediation
Choose One
Submit
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