Confidential Counseling Referral Form

If there is someone you think could benefit from SMYAL counseling please fill out this confidential form and let us know.

Person completing form:


Phone number:


Email address:


Relationship to youth:


Name of youth / Nickname
/

Date of birth:


Social Security #:


Phone number:


May we leave a message at this number for the youth?
Yes No

If yes, what information can the message include?
Name Phone Organization

Address:


Reason for referral:


Youth lives with whom?


Are they aware of her/his identity?
Yes No

Are they supportive of her/his identity?
Yes No

School / Grade
/

Describe school attendance and behavior, if known:


Do you know how youth identifies their gender?
Don't Know
Female
Male
Transgender
Intersex
Questioning

Do you know how youth identifies their sexuality?
Don't Know
Lesbian
Gay
Bisexual
Hetrosexual
Questioning

Does she/he have insurance or Medicaid?
Yes No

Insurance company / Account number?
/

How did you (referral source) hear about SMYAL?
Friend
Radio
Newspaper
School
Family Member
Pride Event
Internet
Coworker
Training
Other

History of treatment (counseling, substance abuse, psychiatric, etc):


Mental health diagnosis (if applicable):


Current medications and reason for medications:


History of legal involvement (arrests, charges, incarceration):


By submitting this form, you are attesting to the accuracy of the information to the best of your knowledge. If any of the above information is found to be inaccurate or misleading, it may be grounds for dismissal from the program.

Name of person completing form:


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Donate to SMYAL
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contact the staff
contact the staff
Get in touch with a SMYAL staff member.