CASA Conncts Referral (360 meetings, resource navigation, short-term case management) Survey

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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

Female

Male

Non-binary

Transgender

Genderqueer/Gender non-conforming

Questioning

Please let us know the gender if it was not listed above.

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* 8. Child/Youth Pronouns

She/Her/Hers

He/Him/His

They/Them

No preference

Please let us know the child's preferred pronouns if not listed above.

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* 9. Child/Youth Race

Hispanic or Latino/a/x

Spanish Origin of Any Race

American Indian or Alaskan Native

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

White

Middle Eastern

North African

South Asian

Two or More Races

Prefer Not to Say

Please let us know the child's ethnicity if it was not listed above.

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* 10. Child/youth ethnicity

Hispanic

Not Hispanic

Middle Eastern

North African

South Asian

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

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

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

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* 14. Caregiver First and Last Name

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

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* 16. What is the families zipcode?

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* 17. Caregivers Phone Number

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* 18. Caregivers Email

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

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

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* 21. 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.)

CASA Conncts Referral (360 meetings, resource navigation, short-term case management)

Question Title

* 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 Race

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* 10. Child/youth ethnicity

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

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

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

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* 14. Caregiver First and Last Name

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

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* 16. What is the families zipcode?

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* 17. Caregivers Phone Number

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* 18. Caregivers Email

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

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

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

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