Name of the person completing referral
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Please check what type of agency/provider you are affiliated with:
Parents
independent Court
Community
Medical
Mental Health
School
Law Enforcement
Division of Family & Children Services (DFCS)
Department of Juvenile Justice (DJJ)
Is the physical custodian of the youth requesting an assessment within 24 hours of submitting the completed referral?
Please indicate any scheduling preferences (preferred day / time).
*
Youth Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Other
Ethnicity
*
Is client currently pregnant?
*
Is client actively parenting?
*
Languages Spoken:
*
Does youth have a disability?
*
Who has custody of youth?
*
Parents
Father
Mother
DFCS
DJJ/Court
Other Family Relative
Other
Listed/Legal Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
County
*
Current Location
County
Is this a safe location?
*
Name of Legal Guardian
*
First Name
Last Name
Phone
*
(###)
###
####
Name
First Name
Last Name
Phone
(###)
###
####
Prior history of exploitation:
*
Please check all that apply
*
Family/Household Information: (in-home abuse or neglect, family functioning, other siblings, etc.)
*
Medical History: (pregnancies, STDs/STIs, chronic health conditions, recent medical exams, etc.)
*
Mental Health Involvement: (substance abuse history, mental health diagnosis, current therapeutic provider, etc.)
*
Juvenile Justice Involvement: (if no, put N/A. If yes, please include a name or contact, and list any active warrants or charges, if applicable, etc.)
*
Child Welfare Development: (please provide contact information for Case Manager)
*
Prior to completing this referral, did you utilize the Georgia Statewide Screening Tool?
*
Youth Name
*
First Name
Last Name
Youth Date of Birth
*
MM
DD
YYYY
Checkbox
*
Signature of Youth
Date
MM
DD
YYYY
Name of Parent/Legal Guardian:
Date
MM
DD
YYYY
Signature of Parent/Legal Guardian:
Print name of the person completing referral:
*
Text
Signature of the person completing referral:
*
