Free 360 Facilitated Meeting Referral
1.
Referring Party First and Last Name
2.
Referring Party Organization
3.
Referring Party Phone Number, Email, and Supervisor's Name
4.
Is an Interpreter needed for this meeting? If so, what language is needed?
5.
Child/Youth First and Last Name
6.
Child/Youth Date of Birth & Age
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.
8.
Child/Youth Pronouns
She/Her/Hers
He/Him/His
They/Them
Ze
No preference
Please let us know the child's preferred pronouns if not listed above.
9.
Child/Youth Ethnicity
White/Caucasian
Black/African American
Asian/Pacific Islander
Hispanic/Latino
Multi-Racial
Indigenous/Native/American Indian
Please let us know the child's ethnicity if it was not listed above.
10.
Is the child/youth covered by insurance?
11.
Please include the type of insurance (Medicaid, United, Kaiser, etc.)
12.
What is the school name and grade of the child/youth?
13.
Caregiver First and Last Name
14.
What is the caregiver's relationship to the child?
15.
What is the families zipcode?
16.
Caregivers Phone Number
17.
Caregivers Email
18.
Please let us know if there are any cultural considerations that need to be considered.
19.
Please provide at least 3 dates/times that work for a one hour virtual meeting (for caregivers)
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.)
21.
What are the primary issues for the child? (Example: Mental Health, Substance/Alcohol Use, Behavioral Health, Education, etc.)
22.
Is there anything else we need to know about this referral?