CII LAUNCH Program for Transition Age Youth (TAY) - Referral Form

CII is launching a new program focused on building relationships between current and former system-involved youth (ages 14-27), mentors and peers. This new program is intended to support youth's educational success, identify meaningful career opportunities, support emotional and physical wellness and develop a network of support for navigating life's journey. Fill out the form below to refer a youth into this program and a CII staff member will follow up. Thank you for your partnership!

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* 1. Contact Information of the Referrer

Full Name

Organization

Phone #

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* 2. Referred Youth Information

Full Name

Date of Birth

Zip Code

Phone #

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* 3. Does the youth have current or previous involvement in the child welfare or probation systems?

Yes

Other (please specify)

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* 4. Does the youth currently reside in Long Beach or the surrounding areas (SPA 8 - South Bay)?

Yes

Other (please specify)

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* 5. Is it okay for a CII staff member to contact the youth directly?

Yes

No, please contact referrer

No, please contact the caregiver

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* 6. Please feel free to provide any additional information/context you'd like us to know.

Thank you for your time in filling out this survey.