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Direct Connect Advocate Referral
Name of adult completing the form:
(Required)
First
Last
Adults Phone Number
(Required)
Last 4 digits of youth's phone number:
(Required)
First 3 letter of youth's last name:
(Required)
Youth's Zip Code
(Required)
Health Insurance
(Required)
Untitled
(Required)
Depressed mood
Loss of interest in activities
Appetite change
Emotional changes
Sleep disturbance
Decreased energy
Feelings of worthlessness
Hopelessness/Helplessness
Substance use
Substance abuse
Excessive school absences
Decreased concentration
Self-injury
Excessive worrying
Restlessness
Difficulty concentrating
Complicated grief
Easily irritated
Muscle tension
Unexplained pain
Racing thoughts
Risky behavior
Reactive anger
Please specify what the young person has said or done that indicates the need for a referral:
I understand that by completing this form I am referring the youth identified on this form to mental health services for the reasons that I have expressed directly to the youth. I attest that the young person is aware of this referral and willing to speak to a mental health provider.
(Required)
Yes, I understand
