Referral Form

Date *

Person Referring (and name of agency/school if applicable) *

Referral Source Email *

Referral Source Phone *

Parent/Guardian Name (if client is a minor)

Client's First Name *

Client's Last Name *

Client's Birth Date *

Client's Age *

Client's Social Security Number

Gender *

Race/Ethnicity *

Name of School & Grade – Type N/A if not applicable *

Client's Street Address *

Client's City, State, Zip Code *

Client's Primary Phone Number, Including Area Code *

Client's Secondary Phone Number, Including Area Code

Email

Preferred method of contact *

Text
Phone
Email

Is guardian or adult client aware of the referral? Family needs to be aware of referral prior to placing it. *

Yes

May we leave a message? *

Yes
No

Is an interpreter needed for the client? *

Yes
No

Client's Primary Language

Is an interpreter needed for parent (if client is a minor)

Yes
No

Parent's Primary Language (if client is a minor)

What are your concerns about the client? Select all that apply. *

Other *

Preferred Service Type (Please note our maximum length of stay is 6 months. Be advised that we have wait times for our various programs, please contact our Intake Department for more details 614-294-2661 or Intake@dfyf.org) *

Community-based (Youth only)
Office-based

Insurance Information – to facilitate faster access to services (Insurance Company Name and Policy Number)

How did you hear about DFYF?