Referral Form : Esther's Home : Mirror Ministries

Date: (Required)

Referent Name:

First Name *

Last Name *

Referent Phone: (Required)

Youth’s Legal Name:

First Name *

Middle *

Last Name *

Youth’s Preferred Name:

First Name *

Last Name *

Date of Birth: (Required)

Age: (Required)

Gender Assigned at Birth:

Female
Male

Gender Identification:

Female
Male

Who has custody of the youth?

Parent/Guardian
In State care
Other

Youth Custody (Required)

If Parent/Guardian, please provide name. If State care, please provide State:

Current living arrangement:

Both Parents
Single Parent and/or Shared Custody
Living with relatives/Homeless
Foster care
Other

Parent/ Guardian Name:

First Name *

Last Name *

Parent/ Guardian Phone Number: (Required)

Parent/ Guardian Address:

Country

Address Line 1

City

State/Province

Postal Code

Youth Address (If different from Parent/Guardian):

Country

Address Line 1

City

State/Province

Postal Code

Youth Phone Number (If applicable):

Mental Status at Time of Referral: (Required)

Please provide a brief explanation

Does the family know a referral has been made?

Can they pass a urinary analysis?

A “No” response does not automatically mean disqualification, it will prompt further discussion.

Currently:

Not Pregnant
Possibly Pregnant
Pregnant
Parenting

School

Current Enrollment Status:

Not enrolled
Enrolled part-time
Enrolled full-time

Last Grade Completed:

Last School Attended:

Current School Enrolled In:

Current Attendance Status:

Attending regularly
Challenges with regular attendance
Suspended
Expelled
Other

If other, please explain:

Current School Supports:

504
IEP
Tutor/ Academic Support
Other
N/A or no current school supports

If N/A or no current school supports, we will need copies of documentation. If other, please explain below.

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If other, please explain:

Legal Involvement

Current Juvenile Justice Involvement (Please check all that apply & explain below)

On Probation (Under supervision with conditions)
Participating in Diversion Program (Alternative to formal legal proceedings, focusing on rehabilitation)
Other legal involvement. Please explain.
No current or known legal involvement

Please explain the above selections: (Required)

History of Offenses/ Involvement (Please check all that apply. Explain below):

Offenses involving harm to others or animals (Assault, physical altercations, etc).
Offenses involving property.
Offenses involving fire starting/ arson.
Offenses related to substance use/ possession