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* 1. Referring Party First and Last Name

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* 2. Referring Party Organization

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* 3. Referring Party Phone Number, Email, and Supervisor's Name

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* 4. Is an Interpreter needed for this meeting? If so, what language is needed?

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* 5. Child/Youth First and Last Name

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* 6. Child/Youth Date of Birth & Age

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* 7. Child/Youth Gender

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* 8. Child/Youth Pronouns 

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* 9. Child/Youth Ethnicity 

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* 10. Is the child/youth covered by insurance?

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* 11. Please include the type of insurance (Medicaid, United, Kaiser, etc.)

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* 12. What is the school name and grade of the child/youth?

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* 13. Caregiver First and Last Name 

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* 14. What is the caregiver's relationship to the child?

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* 15. What is the families zipcode?

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* 16. Caregivers Phone Number 

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* 17. Caregivers Email 

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* 18. Please let us know if there are any cultural considerations that need to be considered. 

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* 19. Please provide at least 3 dates/times that work for a one hour virtual meeting (for caregivers)

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* 20. Please include the name, organization, phone number, and email address of any Collateral/Support/Professionals who the family is working with (Example: DHS worker, other family member, teacher, GAL, Counselor, CASA, Coach, Mentor, etc.)

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* 21. What are the primary issues for the child? (Example: Mental Health, Substance/Alcohol Use, Behavioral Health, Education, etc.)

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* 22. Is there anything else we need to know about this referral?

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