SunServe Youth Referral Form Ver 2.0

SunServe - Youth Referral Form

Please be sure that all required fields are completed and that all data is accurate. If you need help please email: youth@sunserve.org
Date

MonthDayYearHourMinutes
From
If the individual you are referring is in a crisis situation or subject to potential danger DO NOT fill out this form! Instead please contact the Y.E.S. Team at Henderson Behavioral Health at (954) 677-3113 or simply dial 911. By checking the circle below, you are confirming the individual being referred is NOT in a crisis situation or subject to potential danger.*

I Confirm
The requirements for receiving services from SunServe's Youth Department are as follows:
- You must be a resident of Broward County, FL
- You must identify as LGBTQIA+
If you wish to attend our youth social support groups, you do not need to complete this form. Contact Mario DePedro at mdepedro@sunserve.org for more information about our youth groups.
Who is submitting this form?*

Self (youth)Legal GuardianOther
If other, please enter full name
Legal Guardian Last Name*
Please double check your entry
Legal Guardian First Name*
Please double check your entry
Youth Last Name*
Please double check your entry
Youth First Name*
Please double check your entry
Youth's Date of Birth*

MonthDayYear
Date
Youth Current Age
Youth's Current Grade
Youth's school ID number
Last 4 digits of youth Social Security Number
Is the youth currently in foster care?*

Yes, currently in foster care/extended foster careNo, they have never been in foster careNo, they have aged out of foster careNot sure
What is the household size?*
Total number of people in home
While our services are free of charge, some grants require additional information regarding income and insurance. This helps us when placing clients, this will not stop services from being rendered.
What is the annual household income of the youth (or their guardians if under 18)?*
What is the annual household income of the youth (or their guardians if under 18)?*
Does youth have health insurance?*

YesNoNot sure
If youth has health insurance, what is the provider's name?*
Is the above plan a Medicaid plan?*

YesNoUnsure
Youth's Preferred Pronouns*

They/ThemShe/HerHe/HimUndecided/Unknown
Youth Identifies As:*

LesbianGayBisexualTransgender Male/masculineTransgender Female/feminineGender Non-conforming/Gender Fluid/Non-binaryQueerPansexualPan romanticAsexualOther
Program(s) of Interest*
Street Address *
City*
State*
Zip Code*
Five-digit US postal code
Phone Number*

Area CodePhone Number
Email*

Confirmation Emailexample@example.com
Comments
Optional
SunServe - Social Services

www.SunServe.org - (954) 764-5150 - youth@sunserve.org
Should be Empty:

SunServe - Youth Referral Form

SunServe - Social Services