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JOIN THE INSPIRED YOUTH
INSPIRED Youth Referral
Referral Date
*
Participant Information
Participant First name
*
Participant Last name
*
Participant Date of Birth
*
Participant Gender
Participant Ethnicity
Black
Hispanic/Latino
Asian
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
White
Participant Address
*
Parent/Guardian Information
Parent/Guardian Full Name
*
Parent/Guardian Address (if different than participant)
*
Participant Email
Parent/Guardian Phone
*
Relationship to Participant
*
Preferred Method of Contact
Text
Call
Email
Insurance Information
Individual/Family Insurance
Self
Spouse
Dependent
Parent/Guardian
Other
Insurance Provider
Group Number
Policy Number
Reason for Referral
Does the Youth Have a History of Substance Misuse?
Does the youth have a history of behavioral concerns, aggression/violence, or criminal involvement?
Does the youth have a history of suspension/expulsion?
Does the youth have a history of mental health concerns?
What are some skills/areas of growth for the youth and/or family of youth?
Does the youth have an Individualized Education Plan (IEP) and/or 504 Plan?
What school is the youth currently enrolled in?
What grade is the youth in? Also, if the youth has previously been held back, what grade would they have been?
Is the youth currently enrolled in Florida Virtual School?
Do any of the following apply to the person being referred? (Please check all that apply.)
Learning Disability
Deaf an/or Hard of Hearing
Blind/Vision Problems
Active Substance Use
History of Substance Abuse
Mental Health Concerns
History Violence
Literary Deficiency
Language Barrier
Spoken Language
Other
Please Include Copy of IEP, 504, Agency Referral, or Other Relevant Documentation
Upload File
Submit
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