Region 3 YRCC Referral Form (Ages 13-21)

__________________________________ __________________________ ____/_____/ 2010

YRCC Agency Name Source of Referral (e.g., Walk-in, Outreach

______________________________________ ______/______/_____ _____ Gender M F

Last Name, First Name Date of Birth Age DCFC Ward? Yes No

______________________________________ ______ 606____ ( _____ ) ___________ - ______________ Police Dist. ______

Street Address Apt # Zip Code Phone #

In School? __________________________________________ CPS School? ______________________ First time seen by YRCC? Yes
Yes No If “Yes”, School Name Yes No Grade Primary Language No

______________________________________________ ( ______ ) _________ - _______________ EMAIL: _______________________________

Name of Parent/Guardian Home Work Mobile Phone
_________________________________________________________________________________________________________________________________
Place the Referral Code Number on the line next to indicated services/programs. (If no Referral is made please indicate in notes as a Referral code #5)
Counseling Employment Social Services Notes
___ Individual ___ After School Matters ___ Food Assistance __________________________________________________
___ Family ___ Job Training ___ Financial Assistance __________________________________________________
___ Assessment/Evaluation ___ Job Referral ___ Clothing Assistance __________________________________________________
___ Other______________ ___ Job Placement ___ Health Assistance __________________________________________________
___ Other______________ ___ Child Care Referral Codes (write the corresponding # for referral)
___ Case Management 1--- Referral to other CPS/After School Matters Program
Youth Development Education ___ Court-Required Comm. Svc Name:______________________________________
___ After School Matters ___ Service Learning ___ Other __________________ 2 --- Referral to another CYS Agency
___ Mentoring ___ Drop-out/Re-enter School Name:_____________________________________
___ Art/Culture ___ Alternative Placement Participation (check one) 3 --- Referral to Partner Agency, Linkage? Yes No
___ Sports/Recreation ___ GED Program/Placement 0-30 Hours Name:______________________________________
___ Personal Development ___ Tutoring 31-60 Hours 4 --- Referral to City of Chicago Department Agency
___ Technology ___ Safe Passage 61-100 Hours Name:______________________________________ ___
Youth Council ___ Post-Secondary 100+ Hours 6 --- Referral to Violence Prevention Programming
___ Other_____________ ___ SMART Program _______ # of Days Name:______________________________________