New Referral to FLY

NOTE:: Please be careful and cognizant while inputting professional and youth details; be aware that each line is pertinent to details FLY uses to guide the process of providing support for this young person.

Once you have submitted the referral, a confirmation will arrive via email.

When we are able match this client, we will reach out to you regarding the next steps.

Thank you for referring your client to FLY, we are grateful to be considered as the service support for your client!

Please reach out to referrals@fullyliberatedyouth.org with any questions.

Client Services *

Transitional Services - Accepting New Clients

Case-Management - Accepting New Clients

Mentor/Youth Advocacy - Accepting New Clients

Family - Accepting New Clients

EMDR - Accepting New Clients

School Based Therapy - Not Accepting New Clients

School Based Mentoring - Not Accepting New Clients

GED - Not Accepting New Clients

Individual - Accepting New Clients

Referring Party Information

Judicial district

System

Referring Title *

Professional Referral Name *

Referring phone

Referring Email *

Referral preferred service type

Client Information

First Name *

Last Name *

DOB *

Referral case number

Phone *

Address 1 *

City *

State

Zip *

Legal Guardian Information

Guardian First Name *

Guardian Last Name *

Guardian Phone *

Guardian relationship

Guradian Address is same as Client

Guardian Address *

Guardian City *

Guardian state

Guardian Zip *

About the Client

Spoken Languages *

Race / Ethnicity *

Sexual Identity *

Sexual Orientation *

School name

Suicidal Ideation or Attempts * Yes No Unknown

Victim/Suspected Abuse * Yes No Unknown

Victim/Suspected Abuse Note *

Teen Parent? * Yes No Unknown

Mental Health Diagnosis? Yes No Unknown

Mental Health Diagnosis Elaboration *

PTSD Yes No Unknown

Does the client need Vital Documents and/or ID? Yes No Unknown

Which Documents? *

Prescribed Medication(s)? * Yes No Unknown

What Medication(s)? *

Adult charges? * Yes No Unknown

Firearm access in the home Yes No Prefer not to answer

Is the service mandated by the courts? * Yes No Unknown

Alcohol Yes No Unknown

Gang Involvement Yes No Unknown

Gang Involvement Elaboration *

Substance Use (if so, indicate drug of choice)

Education

Employment notes

Preferred FLY Provider

What more information can you provide for consideration as we match the appropriate/preferred FLY provider *

Hobbies/Interests *

Goals / Domains *

Client Files

Referral Upload Release of Information if available

Referral Additional Legal / Clinical File? (Police Report, Mental Health Evaluation/Intake)