GENERAL REFERRAL FORM

By providing information, you are attesting that either (1) you are your own guardian making a self-referral, (2) you are the youth's parent/guardian or (3) you have consent from the youth's parent/guardian to share this information. In any case, please be aware that the client and/or youth's parent/guardian will be contacted by an agency representative to obtain consent and in order to provide assistance in identifying appropriate services. If you do not provide the parent/guardian's contact information or if a parent/guardian cannot be reached to provide consent, the agency representative will not be able to follow up.